Question
What is the name of your state? Wisconsin
I've been appealing a medical claim from an April doctor's visit, and while awaiting the appeal results, I discovered that my medical insurance failed to apply amounts to my co-insurance. This error resulted in erroneous additional charges.
Although the actual appeal was denied, my insurance company is now reprocessing the claim to correct the mistake with my co-insurance payment.
I have been continually updating the medical provider on the status of my appeal, and this morning I called to inform that the claim is being reprocessed due to the insurance company's mistake.
They replied that, since they had to wait so long for the appeal to be reviewed, they refuse to wait while the claim is reprocessed. They are now threatening to send my account to collections.
Does anyone know what, if any, legal recourse I have? Are there any standards that govern a provider's dealings with a patient during the insurance company's appeal process or reprocessing of a claim?
Thanks!
Answer
Unless your doctor has a contract with your insurance company that states otherwise, he does not have to wait for your insurance company. He can demand payment from you and then YOU would get the reimbursement from the insurance company.
Call your insurance customer service department and ask them this question; if he is contractually prohibited from billing you until the appeal issue is resolved, they will tell you.
Answer
Thanks for the reply!
What about the physician's adherence to some sort of standard of conduct or ethical practice? Does the AMA, State Medical Board, or some other institution have standards with which doctors voluntarily comply? Does anyone know whether something like this exists? Perhaps there could be a standard that directs physicians to work with patients during the billing/appeal process.
Thanks, again!
Answer
Perhaps there could be someday, but at the present time there isn't that I know of.