Author Topic: Is patient legally responsible for timely filing error made by biller?  (Read 2702 times)

Tke490

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Hi,

I have an urgent problem that I was hoping someone could help me with.

I am a patient who had a hip surgery that was initially denied by the insurance company due to "Experimental procedure" (even though they covered a very similar procedure for my other hip 9 months earlier).  The physician's office filed an appeal which was subsequently denied.  Then they filed a second level appeal more than the 60-day deadline that insurer had for filing the appeal (so the appeal was denied due to untimely filing).  The physician's office is now saying that I am responsible for paying the bill that the insurer denied because prior to the surgery I signed one of the disclaimer forms that said I would pay if the insurer denied my claim due to several potential reasons (one reason being an experimental procedure). 

I am so scared that I may have to pay this multi-thousand dollar bill which I cannot afford, however, I don't believe I should have to since the medical biller missed the deadline. 

Can someone tell me if I am legally responsible for paying this bill?  I read in another section of this website (see link below), the following with regards to Denial of a Medical Claim:

http://www.solutions-medical-billing.com/denialofmedicalclaim.html

"Step 6.  The representative may tell you that the claim has been denied correctly. That does not necessarily mean they will not pay. The claim may have been denied for timely filing. If the billing office resubmits the claim with proof of timely filing, the decision may be reversed. (Incidentally, if the claim is denied for timely filing, the patient cannot legally be billed.)"

Please - if anyone has any advice or information that I can counteract the medical biller's argument I would greatly appreciate it.  Please feel free to email me at Tke490@aol.com.

Thank you so much!

Michele

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The problem with step 6 below is that it is referring to a claim being submitted, not an appeal.  If a claim is submitted by a participating provider and it is denied for timely filing the patient cannot be billed.  However, this is a different situation.  I would recommend that you contact your insurance carrier directly and ask if there are any appeals that you can file yourself.  Explain that the provider is billing you for the entire procedure.  I would also go directly to the dr and make him aware that the 2nd appeal was denied due to the fact that his biller didn't file the appeal in time.  60 days is common for an appeal.

Best of luck.

Michele
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