Question
What is the name of your state?What is the name of your state? Michigan
I visited an out of network Dr. who would not do insurance billing and took 100% payment at time of visit. The insurance company sent me forms for reimbursement which I filled and returned to them.
The insurance company sent the payment to my doctor instead of me. Now they have washed their hands of it and will not correct the matter. The Doctor's office has not answered their telephone nor returned messages.
What recourse do I have? Can the insurance company really consider this a closed matter and I have to chase the Dr. for payment?
Answer
I'm not aware of any reason the insurer would be responsible for resolving this.
My suggestion is to write a letter to your doctor's practice administrator explaining the situation and requesting a check within 5 business days. Send the letter by certified mail with return receipt.
If that doesn't work, you would be able to take them to small claims court. It's unlikely this will be necessary. Health providers are aware that it is fraudulent to double bill or retain double payments they are not entitled to. It sounds like a case of incompetence or simple errors rater than intentional fraud. Failing to rectify it would make it fraud, though, so they're likely to jump to it and reimburse you.
In your letter, you may wish to quote the following:
Section 1848(g)(1)(B) of the Social Security Act requires beneficiaries be refunded promptly when errors occur that caused them to pay funds they were not responsible to pay.
“Promptly” is normally defined as within 30 days.
Those quotes apply to Medicare only. However, most healthcare providers follow Medicare principles and regulations with non-Medicare patients as well.
Answer
Chances are, it's going to take them more than 5 business days to get your check processed and mail it to you.
The office, like most offices, should have some sort of credit balance report and it will get caught. You can call and request the money back from the physician.
Since they don't par with your insurance carrier, they (ins.) processed the claim and paid it, per your request (that would be the claim you sent them).
It is kind of odd that they paid the provider, most pay the subscriber, but weird things happen all the time like that.
It is unlawful for them to keep the double payment, so it will be rectified.
Good luck to you with this.
Answer
Just a long shot, but you could call the insurance company and advise that you , not the doctor, sent in the claim due to out of network and ask them why it went to the doctor and not you. They may issue a refund request to the physician, then make payment to you. I have had patients do this before and most insurers will do it.