Author Topic: Is patient legally responsible for timely filing error made by biller?  (Read 1132 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!

PMRNC

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Your situation is a bit more than timely filing, it's the timely filing of an appeal..Legally the provider can hold you responsible, however you have another angle from which to go at it by. Contact the provider and find out what you need to file an appeal, call the insurance company and explain the situation, YOU as the insured have more weight with the carrier than the provider and if the provider wants his money it would behoove them to cooperate with you to get the claim paid first through the insurance. No promises though, you will need help from the doctors office, operative report and any findings and clinical evidence to support this being not an experimental procedure.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

oneround

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Ditto with Linda.  Also, was this procedure auth'd?   The HP would have had to been advised that this was considered an experimental proceedure and in most cases they would not have auth'd it nor would it have been covered.
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

PMRNC

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Good one Michael, had not thought of that quick enough. Even if no authorization required, it would seem reasonable to think a provider doing those type of procedures would be used to filing a pre-determination of benefits as well which may have alerted the patient prior to the procedure.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com