who pays the medical bill

[Florida7979]

I just received a notice from my former medical insurance company that they denied a claim recently filed by a doctor for a procedure that was done over a year ago.Who is responsible for the bill which is over $8,000. I paid all my co-insurance and out of pocket for the year when I was with the insurance company.

 

[cbg]

Not enough information to say, but there's at least a reasonable possibility that you do.

 

[army judge]

I just received a notice from my former medical insurance company that they denied a claim recently filed by a doctor for a procedure that was done over a year ago.Who is responsible for the bill which is over $8,000. I paid all my co-insurance and out of pocket for the year when I was with the insurance company.

Generally, as the guarantor for any medical service (insurance aside), YOU are ultimately responsible.
Insurance is an option, but MOST services require approval or referral.
One glaring exception is "Medicare".
There are a few others.
As "cbg" noted, you haven't given enough information for us to say definitively.
But, don't reveal too much more information.
I suggest you seek clarification from yoru insurance company before you determine your next steps.

The entire outcome might have been a mistake, so seek clarification from the insurer, then determine what you do next.

You might also seek more information from the provider.
Perhaps the provider completed the claim improperly.
Okay, now go detect.

 

[Betty3]

Someone has to pay & "generally" you would be responsible but as noted it's hard to say for sure on the information you posted. You will need to check further into this.

 

[cbg]

If you want anything more, we'll need to know what kind of insurance plan you have, whether the doctor is in or out of network (if applicable) and whether the bill was submitted previously. Then, we might be able to provide a least an educated guess. With what you've given us, we can't even guess. We can only say it's not impossible that you have to pay it. Which, I suspect, is what you want to know.

 

[disagreeable]

If the doctor was in network, he appears to have violated the contract for payment by not submitting the bill in a timely manner in which case the insurance company should have denied both your and their liability for lack of timeliness. This would be shown by the explanation of benefits. If he was an out of network doctor, he had no such contract and a late submission would be denied by them and you would foot the entire bill. You could appeal their timeliness decision however, most of their adjusted portion would likely have gone to your out of network deductible based on the reduced rate and your coinsurance deductible being higher. If it is the former and the explanation of benefits from the insurance company shows you owe nothing, he is trying to balance bill which is illegal.

 

[cbg]

If the doctor was in network, he appears to have violated the contract for payment by not submitting the bill in a timely manner

Not necessarily so. The insurance carrier I worked for, which is a major, national company, would allow submissions up for to a year and to 18 months in some cases, and we don't know what the status of the bill has been in the meantime. While your suggestion a possible answer, I can think of others that are also feasible. We don't have enough information at this point to say and cannot be making declarative statements of fact.

 

[Disabled Vet]

keep in mind as well... it could have been denied because the medical coding on the bill wasn't correct. You should take the "DETAILED BILL" to someone with vast insurance knowledge. Then they can call and find out why was it denied. My wife owns her own medical insurance company.... This happens all the time.... most of the time it was because it wasn't billed correctly....

 

[Betty3]

You can furnish us the answers to cbg's questions in post #5 or do as Disabled Vet suggested. We can't help on the information provided is the bottom line.

 

[disagreeable]

So, as I said, look at the explanation of benefits.