Question
I live in Ohio. In August, 2004, I fell outside of my home and went to the emergency room to have my back examined. Following this visit, the hospital did not successfully submit a claim to my insurance until after 1 year after my visit. My insurance company denied the claim saying that it was not timely, and they also say in their denial that I am not responsible for the claim either. The insurance also leaves the hospital the option to appeal the claim. In the meantime, the hospital has sent my account to a collection agency. After receiving a letter from the collection agency, I put them in touch with the insurance company and told them that according to the contract the hospital has with the insurance company, I am not liable for these charges, unless the hospital can successfully appeal the insurance company's denial. Nevertheless, the representative from the collection agency said to the insurance company that while he is appealing, he will still continue to demand payment from me. Can the collection agency demand payment even though I do not have to pay (according the contract between the insurance company and the hospital, as the insurance co. tells me)?
How can I end the collection agency's harassment? Can they actually do any damage to me legally? Can they affect my credit rating?
Answer
I've gone through this before, and in Ohio. Basically, from what I was told and they way I had to deal with it was simple.
The hospital and the insurance can battle it out forever, they could care less. They want the money, and they want it now. I ended up having to pay the bill and then in turn get the money out of the insurance company. It was nerve wrecking and time consuming, but a needed evil.
As far as the collection agency, before I can answer about how to "stop" them, is it in house collections or third party?
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How do I find out if they are in-house, or third-party? The collection agency has a different name from the hospital.
Answer
That regardless of whether you pay and try to get reimbursed through your insurance or wait for the hospital to appeal, that you should send a copy of the Explanation of Benefits to both the hospital and collection agency. The EOB usually states on it that this is not the responsibility of the patient.
This way if it is reported to a collection agency you have documented proof that you notified them that this debt was not your responsibiity.
Also if you do pay it there is a chance that you may not get reimbursed from your insurance company, and would have a hard time recouping from the hospital.
Have you contacted the hospital customer service, billing or collections department directly. I would try that route too, advise them that you have the EOB and it clearly states claim was denied for failure to file timely and that this is not patient responsibiilty. Ask them to pull a copy of the EOB or offer to fax it to them for review. Usually, if this in 3rd party collections they can pull it back to the hospital and forward for their appeals department.
And as I tell every one you can catch more flies with honey, so when you call be really nice to the person on the other end, (not that you aren't but in many cases people get really frustrated and yell at the collector, end result is the collector won't take the time to investigate the bill or charges etc...)
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Once you have sent a copy of the EOB showing it is not patient responsibity, no they cannot continue to call you.
Answer
Once you have sent a copy of the EOB showing it is not patient responsibity, no they cannot continue to call you.
I had similar experience, and yes, that's exactly how you need to handle the problem. Collection agency would drop the calling, as they know it's useless.
Answer
Now for a legally ACCURATE answer.....
Following this visit, the hospital did not successfully submit a claim to my insurance until after 1 year after my visit.
Not relevant.
My insurance company denied the claim saying that it was not timely
BS. Contact your insurance company in WRITING and request a FULL response including support for their determination.
and they also say in their denial that I am not responsible for the claim either.
BS. The insurance company has no standing in this to determine YOUR liability to the hospital.
The insurance also leaves the hospital the option to appeal the claim. In the meantime, the hospital has sent my account to a collection agency.
Yep. A lot of people are confused as to the 'role' that insurance company's play in the billing process. The insurance company is YOUR protection, and has no direct relationship with the hospital. The hospital-insurance direct billing is done: 1) as a 'convenience' to you... and 2) to assure the hospital that they get paid.
YOU are the ultimate obligation to pay the bill... and the insurance to either pay the hospital on your behalf... or to reimburse you directly after YOU have paid YOUR bill.
After receiving a letter from the collection agency, I put them in touch with the insurance company and told them that according to the contract the hospital has with the insurance company, I am not liable for these charges
HUH?? Where did you get the belief that the insurance company somehow has a contractual obligation for payment with the hospital??
unless the hospital can successfully appeal the insurance company's denial.
Unless you have some kind of EXTREMELY unusual insurance, the hospital has no obligation to appeal anything to anyone.... other than to expect/demand and even file a suit to get payment from YOU.
Can the collection agency demand payment even though I do not have to pay (according the contract between the insurance company and the hospital, as the insurance co. tells me)?
I have to think that you are simply 'confused' as to the obligations of each party.
How can I end the collection agency's harassment?
By paying for the medical services YOU received... then pursuing your reimbursement claim from YOUR insurance company.
Can they actually do any damage to me legally?
Yep.
Can they affect my credit rating?
Yep.
Answer
What JETTY seems to ignore is that insurance does have a contract with every healthcare provider IN NETWORK. The contract states timelines for submission, negotiated rates and codes for EVERY service rendered, and procedures for submission and dispute resolution.
In case when healthcare provider does not submit reimbursement form on time DIRECTLY to insurance, they loose the right to get reimbursed ALTOGETHER. This is the benefit you get, as usaohol correctly explained, and each time you receive the EOB form.
Now, for any OUT OF NETWORK provider, rules are different, and you get reimbursed fraction of negotiated rate, and have to pay the rest (including any excess above negotiated rate) directly to provider. They are also not obligated to submit, and indeed do that as curtecy.
Answer
What JETTY seems to ignore
He is confusing HMO and PPO 'in network' coverage. There is NOTHING in this thread to even suggest the OP is covered by an HMO or PPO.
Answer
And what 'SuckHead' is too stupid to understand is that he is confusing HMO and PPO 'in network' coverage. There is NOTHING in this thread to even suggest the OP is covered by an HMO or PPO.
He never quits, does he...
No confusion about PPO or HMO, both have in-network coverage, in which case OP does not have to worry about bills beyond normal co-pays and fractions of negotiated hospital rates. Some HMOs even have limited out of network coverage.
Out of network, you pay co-pay, remaining fraction not covered by insurance plus anything on top of the negotiated rate. It is in that case where you worry about billing, and are fully liable for entire charge in case hospital does not submit for you. This is also the case when insurance has no contract with the hospital.
OP: find out if the hospital was in network, this will make all the difference.
Answer
I live in Ohio. In August, 2004, I fell outside of my home and went to the emergency room to have my back examined. Following this visit, the hospital did not successfully submit a claim to my insurance until after 1 year after my visit. My insurance company denied the claim saying that it was not timely, and they also say in their denial that I am not responsible for the claim either. The insurance also leaves the hospital the option to appeal the claim. In the meantime, the hospital has sent my account to a collection agency. After receiving a letter from the collection agency, I put them in touch with the insurance company and told them that according to the contract the hospital has with the insurance company, I am not liable for these charges, unless the hospital can successfully appeal the insurance company's denial. Nevertheless, the representative from the collection agency said to the insurance company that while he is appealing, he will still continue to demand payment from me. Can the collection agency demand payment even though I do not have to pay (according the contract between the insurance company and the hospital, as the insurance co. tells me)?How can I end the collection agency's harassment? Can they actually do any damage to me legally? Can they affect my credit rating?
I took this to mean that the hospital was in fact in network.
Answer
He never quits, does he...
Nope. I continue to expect ACCURATE answers on this forum...
No confusion about PPO or HMO, both have in-network coverage
And where EXACTLY did the OP say ANYTHING about an HMO or PPO being involved??
Oh, thats right... it is just more of your imaginary made-up crap, huh??
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I took this to mean that the hospital was in fact in network.
Lots of people think that the "the insurance company" has some kind of contract with the hospital.
The fact is... as noted in my earlier post, most hospitals prefer to 'direct bill' the insurance company. That does not mean that there is some kind of special contract between them.
The fact remains.... absent anything to the contrary, there are THREE parties to this 'transaction'.... The insured 'patient', the patients insurance company and the hospital. And if the insurance company doesn't pay the bill (on behalf of their insured), the patient is liable for the bill.
Answer
Lots of people think that the "the insurance company" has some kind of contract with the hospital.
They do. It is spelled out in the EOB booklet and states that there are "usual and custom ary" charges that have an agreed upon price for reimbursement from the insurance carrier. This does not matter if the Insurance carrier is HMO POS PPO Blue Options, etc. They are called "negotiated charges" that set a standard reimbursement fee for services rendered.
The fact is... as noted in my earlier post, most hospitals prefer to 'direct bill' the insurance company. That does not mean that there is some kind of special contract between them.
Incorrect. I am unsure of the semantical wording, however, there are agreed upon negotiated fees for all services. Why do you think that some hospitals/medical offices/diagnostic centers do not take certain types of insurance??? B/C they cannot agree upon the fee contract, so the providers decide to exclude certain insurances....
And if the insurance company doesn't pay the bill (on behalf of their insured), the patient is liable for the bill.
That is correct. Regardless of Insurance, YOU (the pt) are ultimately liable for the bill. Filing an insurance claim is truly a courtesy, not an obligation.
Answer
Lots of people think that the "the insurance company" has some kind of contract with the hospital.
The fact is... as noted in my earlier post, most hospitals prefer to 'direct bill' the insurance company. That does not mean that there is some kind of special contract between them.
The fact remains.... absent anything to the contrary, there are THREE parties to this 'transaction'.... The insured 'patient', the patients insurance company and the hospital. And if the insurance company doesn't pay the bill (on behalf of their insured), the patient is liable for the bill.
I agree that most people think that their insurance has contracts with providers and that "their insurance is great" especially these with the new health savings plans which are just negotiating agents.
The OP stated in her last line that the insurance company stated per contract. If in fact,they are a provider under the contract and failed to file timely, and had assignment of benefits on file, then they have to either appeal or eat the cost, many times eat the cost timeliness is not an easy appeal.
It did hit me that **************.....
I do agree though that the patient could in fact be liable for the bill, depending on the insurance company and provider agreement. IE. UHC bought many insurance companies out, they began utilizing discounts based on the existing UHC contracts, the providers were under no obligation to extend these discounts to the companies taken over by UHC and this created mass complications regarding patient responsibility. Patients were told by insurance carrier no responsibility based on contract, and provider was stating there is no contract. I believe these issues are still pending some legal actions.
Regardless the patient had to have recieved a bill prior to being sent to collections, if not a few, and should have followed up and tried to resolve the matter before it got that far. Too many people get the bills and ignore them and say oh I have insurance instead of checking to see if there is a problem.