Doctors said they took my insurance but I got a bill anyways

[MitchellD94]

So back in December 2016 I went to the doctor because I was experiencing a sharp pain in my lung whenever I took a breath. I had been experiencing this pain for over a month and usually I would just wait out the pain in something like this but it just wasn’t going away. So, I went to the doctors office and I presented my insurance to the front counter lady (I was covered by Premera Blue Cross) and she told me that that they don’t take my insurance there but she would try it anyways. This gave me a red flag because I wouldn’t have gone to this doctors office if they wouldn’t take my insurance. After about 5 minutes she says that my insurance was accepted and I was seen by a doctor. I spent about 8 hours at the office because “they were worried it could be something bad” so they took my blood, gave me an X-ray and eventually ordered a CT scan all while keeping me there for the majority of the day. Eventually the doctor tells me that it’s “probably” just something called pleurisy which is just some information in my lung and she didn’t get me any sort of prescription or antibiotics or anything and sent me out. Fast forward 2 years and I have a bill pop up in collections on my credit report for $1700 even though the doctor said my insurance was accepted?? I made a couple calls and figured out that my insurance covered the copay and not the $1700 worth of pointless tests and 8 hours of my time. The whole situation felt shady to me and I should have just went to a different doctors office but the only reason I stayed is because she said my insurance was accepted other wise I would have left. So now I’m stuck with a bill in collections that I feel I shouldn’t have to pay and I just want some advice to see if there’s anything I can do to fight it or at least maybe get it lowered? Thank you for taking the time to read all of this.

[RichardP]

Mitchell, you are dealing with two separate issues here:

1.  Whether the doctor will accept your insurance, and;
2.  What your insurance policy will actually pay for.

Consider these two scenarios, one or both of which may well be the situation in your case:

3.  the doctor accepts payment from your insurance, and your insurance pays little to nothing for the work you had done, because the policy your purchased states that those procedures are not covered, or are covered at a very low rate.

4.  your insurance actually covers the work that you had done and the doctor accepts payment from your insurance, but the insurance payment for the work done in this instance all went to your deductible and little or none went to the doctor.

When either 3 or 4 are true, you end up owing the doctor a lot of money out of your pocket.  If neither 3 or 4 are true in this instance, if your policy does cover the work you had done, then your insurance company maybe screwed up.  In which case either you or the medical office, or both, should have filed an appeal within the time limit imposed by your insurance company.  Both you and the medical office should have received some timely notification from your insurance company that payment was denied.  If neither you nor the medical office received such notification, and you can prove it, you may have a case against your insurance company.  In that situation, you would need to contact a health-care attorney.

[PMRNC]

Ultimately it's up to you to make sure the doctors you see are in your insurance network. As Richard pointed out it's too late now as any appeal would be past the time limit. However, you may not be completely out of luck. IF you never received a bill it would be a violation of the FDCPA to report that debt to a credit agency. I would contact the collection agency and first dispute the debt. Tell them you want a full audit of all billing from the dr's office and them. Don't let them tell you that you have to do it because the collection agency is the party that contracted with provider it's up to them to get this info. Do your request in writing and send it certified mail. If they don't respond you can then dispute with credit agency with documentation showing they did not prove the debt to be valid. If they show you that bills were sent to you and that they billed you in a timely manner then you can try to negotiate with the collection agency or even get the provider to adjust it off. I've had success doing this with my own medical bills.