Question
I went to a physical therapist in the spring of 2003 that I was told by ins co Medica was a par provider on my plan. About 3 wks after my final session I got a form letter from them to pay $131.00 for copays, with no explaination or breakdown of how they got the amount. I paid and attached receipt to the letter.
In mid Feb 2005 I started going to the same provider that is (confirmed) a par provider with my new ins co BCBS of IL. I went once or twice a wek until the end of Sept. Nothing was billed to me. the end of Oct. I told provider that I need a bill, that I have all the EOB's from ins co & I wanted a bill so I could get them paid. According to EOB's I figured I owed around $750.00.
The end of Nov I received a letter from them stating I owed them over $1900.00 and that if I didn't mke arrangements it would go to collections, again with no explaination or breakdown of how they got that figure. I immediately called & talked to my therapist as the person in charge of the billing was not in. She told me she would have that person get in touch with me to discuss the amount to figure out why our figures were so far off.
I then called my ins. co. and asked them to send me a claim summary broken down by provider. They did showing my responsibility as what I had gotten from the EOB's.
The end of Dec. I got a letter from the local credit bureau stating that this provider set this in to collections and if I didn't make arrangement to pay them over $3000.00 by the end of Jan. it would be reported to all three credit reporting agencies. I called the credit bureau immeiately and stated I am disputing these charges, that my records show I owe $750.00.
The person (and I use that term loosely) I am dealing with says that provider says that I owe 1200.00 from 2003 because the provider was not par and so I am resonsible for those charges even though I never got a bill for them, I was billed for copays od 131.00. They also stated that I owe them 1100.00 for charges in feb & beginning of march 2005, stating that when I started going to them in 2005 I didn't have ins. My affective date for the insurance in question was Jan. 2005.
I have been working in the ins. field for over 5 years. and I would not go to any provider if I didn't have coverage and I always confirm with the ins. co. and the provider that I am covered for the services and the provider I am being seen for.
I contacted my ins. co from 2003 and was told the they have no claims filed by provider and one rep told me that the provider was non par in 2003(according to the provider) whom she called to ask, rather than checking their records. I then called back and spoke with another rep without telling who I was and asks if the provider was par, I as told no, I then asked why they were listed on the web site, she checked with some and then told me that they were confirming that they are par, I then asked if they could tell me when they became par and was told they have no way of checking that info. and that it was to late for me to file a claim for charges in 2003 even though I never got a bill, still haven't infact. Since I called to dispute this I will send it in writing. Since, am sure verbal won't be good in this case.
So, I really need help, and quick!!!
ps. I have been a CSR for BCBS MN since Sept., and I cannot beleive that there is no way to get me the info I need from 2003, because if that is the case, Medica is sooooooo far behind. I would not have any problem get this info our members. Including if they even tried to file the claim.
Answer
You got a form letter from them to pay $131.00 for copays
Who is them?
Do you have copies of the EOB for all bills in question, that prove your point these were par providers?
Answer
Them is the providers office, I found two EOB's from 2003 one was reversing the payment to their office because they were non par. The other one was for the same dates of service filed under the physical therapist because she was par, this one shows a 15.00 copay per visit. On the records the collection agency sent me shows they didn't get paid for a group of dates of service, I have requested the insurance co. send me copies of all claims submitted to them, and all the EOB's for the time period in question. I beleive they thought hey submitted them all, but missed a few dates.
I also faxed a copy of the letter from my 2005 ins co showing my active dates and a note that I have confirmed with the ins co that they didnot receive the claims for feb 10 when i started going there thru the first date they recd of mar 10, and that they have until june 31, 2006 to get them filed.
The provider is saying I didn't have coverage for those dates. The ins co's letter shows effective dates are 1/1/05 - 12/31/05. These claims amount to 1150.00 of which I may owe up to 39.00 in co ins. For every 175.00 billed the insurance co is allowing 129.90 and my co in of 10% is 12.99.
So I don't think I'll have any problem with 2005's because if they still refuse to resubmit the one's not paid I am to let my ins co know and they will call the provider to straighten it out because they are par with the ins.
My main concern right now is if they can hold me responsible for bills they didn't get paid for in 2003 since there is a block of dates again amounting to 1200.00 that they show were not paid. These dates fall between the first month and third month I went.
I have ordered copies of all claims submitted, all EOB's and letter of proof of ins. with effective dates. I hope to be able to show with these that they were par and therefore responsible for making sure their claims were paid.
But I don't know if that is enough.
does this help?
Answer
forgot state is Minnesota
Answer
Unless you have something in writing to contradict the EOB, that will be what the carrier relies on in denying/approving your claim. If the EOB says the providers are non-par, then you have a weak case.
If the providers in question are non-par, you are probably going to be liable. If they are par, they (providers) may have to eat the claim for failure to file on a timely basis.
A lot up in the air here.
Answer
The provider was par, they originally submitted the claims with the clinics provider ID and it came back as non par and paid the non par benifits. when they told me this I called the insurance co and was told they submitted under the wrong id. I let the provider know that per the ins co they were to resubmit using the individual provider id as it was the therapist that was par. the provider did resubmit and I have found two of the EOB's for the same two dates of service one under clinic(taking back the payment to nonpar provider) the other one showing paying to the par provider (the therapist) show copay due, which I paid. However they apparantly didnot submit claims for 3-4 dates of service. That is what they are trying to charge me for 3 yrs later. The only bill I ever got from them was the one for $131 that I paid. I didn't know anything about the other amount until I called the collection agency to dispute the amount they were saying I owed in the collection letter dated Dec. 29, 2005 (these were charges from 2003 and ins co states it is long passed the timely filing date) - So am I responsible for a bill for a par provider, that they didnot submit to my insurance, three years ago, and that I had NO knowlegde of until 3 years after the services were preformed.
I don't know if it has any bearing that I went back to the same provider 2 yrs after this for services, and never was there any mention of me owing for a past bill. Also, when they sent me a bill for last years services these charges were not on that bill either. These charges didnot show up until they sent it to collection 20 days after sending me the bill for the 2005 charges.
Answer
It seems you are building much of your argument on things you were told 3 years ago. Not saying you are wrong, or right. But what will prevail in your fight is proof.
You say one thing. The provider & carrrier say something else.
The bottom line is this. The provider rendered services and is entitled to payment. You signed a financial responsibility form when you used this provider, ultimately making you responsible if the carrier fails to pay.
If you cannot prove this was a par provider, you have nothing to justify your refusal to pay this claim.
You may in fact be in the right, but without substantiation of your claim you will have to pony up.