Author Topic: Who is responsible for bill?  (Read 1527 times)

pbarnak

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Who is responsible for bill?
« on: December 04, 2009, 10:55:35 PM »
I recently received knee injections for osteoarthritis which is an alternative to surgery. I have insurance and was told by the Dr.'s office that I was 100% covered and only needed to pay my co-pay. They said they got approval from my insurance company. After the last shot, (1/wk for 5 wks) I was told I have a bill. Total amount is $1400.00, and it turns out that it was considered as surgery so it fell under my deductible ($2000.00/yr). After calls to the Dr.'s office manager, he said the insurance company has no record of the call. So either the insurance is lying or the person in the Dr's office never made the call. The dr office is filing an appeal.

Since I was assurred that I was 100% covered by my insurance as per the doctor's office, am I repsonsible for the total amount or since they made the mistake, it is up to them to cover the amount. If there appeal is denied, then I will file an appeal with the insurance company. What else can I do?

Thank you.

PMRNC

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Re: Who is responsible for bill?
« Reply #1 on: December 05, 2009, 10:18:18 AM »
If the fee went to your deductible, the carrier did cover it, but that is your out of pocket. If you have a deductible and coinsurance that is your cost sharing according to your policy and has to be paid for benefits to be paid out.
So technically speaking and without more information it appears as though you would be responsible for the services and anything that was applied to the deductible.

Also when either you or the provider verifies coverage and benefits, insurance companies will tell you that it is "Not a guarantee of benefits, charges are processed according to the patient's plan benefit at the time of service"

Next time, check with your carrier and you need to know if you have deductibles and any out - of pocket. Just because it went to your deductible does not mean the carrier gave misinformation, they did cover the services but it was applied to your deductible which you would be responsible for.
Linda Walker
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Pay_My_Claims

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Re: Who is responsible for bill?
« Reply #2 on: December 05, 2009, 11:41:46 AM »
Linda is correct. Unfortunately they (md office) didn't do a good job at obtaining your benefits. I don't think they would have done all they did without collecting something upfront had they been fully aware of what the benefits are. It seems the issue was they called to get medical office benefits but should have asked about the procedure. Regardless it applied to your deductible and unfortunately you have to pay.

Steve Verno CMBS, CEMCS

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Re: Who is responsible for bill?
« Reply #3 on: December 06, 2009, 09:15:08 AM »
To add, Linda, is 1,000% correct. A health benefit may be covered and payable.  but if you have a deductible to meet, the payment of your benefit is transferred to you via your deductible.  Example:

Popeye has insurance with ABC Insurance.  He as muskle repairs and wound repairs as a covered benefit. The repairs are payable at 100% of ABC insurance usual an customary allowable.  He has a $2,000 deductible and a $25 copay.  While visiting Olive Oyle, he gets into a fight with Bluto.  he sustains damage to his left deltoid muscle and an open wound on his forehead.  He is treated by Dr, Whimpy. The claim is sent to ABC Insurance for $1,000.  ABC allows $1,000 and applies $975 to the deductible and $25 to the copay.  ABC paid the full claim at 100% an required popeye to pay the copay and deductible.  If Popeye has the same problem again, ABC will issue a check to Dr. Whimpy because to them, Popeye met his deductible but Popeye will still have to pay the $25 copay.

Your insurance company should have sent you an EOB as to how they processed the claim. 

Now, lets say Popeye is covered for repairs and he has a $1000 deductible.  Ony this time Popeye's policy says ABC pays 60% of their allowed amount.  It says Popeye pays the 40% of the allowable and any amount above the allowable.  What this means is Dr. Whipy charges $1,000.  ABC allows $500.  ABC pays $300 whih can also be applied to the deductible.  Popeye pays The remaining $700.  The service was covered and paid per the contract wih Popeye.
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