Insurance Question - Aptos,CA

Dear S.,
I am an insurance agent and have dealt with millions of billing and claims issues. I would start with your insurance company. If you are still receiving bills from the hospital, it sounds as though perhaps your insurance was never billed. Have a pen and paper ready and document the date, time, and name of the person you speak to and write down notes pertaining to the conversation. Have a bill with you when you call so that you can give them the service date, the provider name, and the billed amount. (With x-rays you may have more than one bill: from the hospital or doctor office who did the x-ray and then from the radiologist who read the x-ray and sent the report to your doctor). Make sure you have everything gathered when you call. Not knowing which specific insurance carrier you are using, it's hard for me to say how their claims system works. If they say they have no claims for that date of service, tell them you will speak to the provider billing department, but ask for where to tell the provider to send the claim for expedited processing. Make a copy of the information you write down to take to the provider billing department with you or contact them by phone and ask if they need it faxed to them for your file.
The only other thing I can think is that the charges for your x-rays may have been applied to your calendar year deductible for 2009 in which you would have to pay the bills, or some of them, depending on how much of your deductible had been met. If that were the case, and the insurance was billed, you should have received something called an Explanation of Benefits from your insurance carrier outlining that for you.
Unfortunately, claims mistakes are pretty common on both the provider and insurance sides of things. After this long, you really need to step in and get to the bottom of things. I had one client, who was an attorney of all things, who kept getting claims for service denied. She was getting nowhere with the insurance company or the provider and she finally brought them to me (it had almost been a year). I had her file for about 5 minutes and new immediately what was wrong. The provider had mistakenly, and repeatedly submitted her claims with a procedure code used for infant services on the billing. The woman was 53 years old so the claims were obviously denied. I had the provider correct the procedure codes and resubmit the claims to a case manager I had requested for expedited processing and it was all taken care of.
Your new deductible has nothing to do with anything that happened last year. When the bill arrives does not change your date of injury or service. And it is frustrating, but your insurance company should be able to send you something showing your claims history for 2009 and what charges were applied to deductible, what was paid on, etc. If they have nothing for your charges related to your x-rays, then you need to get the provider to submit those claims. In my experience, labs and ancillary providers such as radiologists seem to be the ones who somehow fall through the cracks when it comes to insurance billing and it's never safe to assume that just because we have insurance, claims will automatically be submitted properly and paid.
I would gather everything you have and spend some time on the phone Monday getting the ball rolling toward resolution. And again, document your conversations and who you speak to so that if you have to call again, you can say, "I spoke with _________ on March 1 and she said_______."
If the provider says they will send the claim out next week, give them until the following week and call to confirm it's been done. Then, follow up with the insurance carrier to make sure it's been received. It takes some work, but it's worth following up on.

Let us know how it goes and write me if you have any further questions.

I use to work at a hospital's billing office and we use to get this complaint all the time. Our office would actually bill up to a yr after the insurance paid (it can take an insurance company up to 6 months to make their payment too). Talk about a lot of not so very happy patients. However, as the previous post mentioned the amount the insurance covers is based off the dates of service. So you won't be getting a bill for this yrs deductible. Your insurance company processes based off of the date on the claim. But if you are still getting treatment this year for the same injury then yes you would have to meet your deductible again.

Having said that I would do two things. First, I'd call the insurance company and see if they received a claim from the doctor/hospital for that date you were seen. Unfortunately, in most cases the hospital/doctor only bills your insurance as a courtesy for you. So the bottom line (even though you feel like it isn't fair) the bill is your responsibility to resolve. When you call the insurance company just state you want to check status on your claim for the Date you were injured and for wherever you had the xrays done. You usually will have to have the original billed amt as well. Hopefully they will tell you they have the claim and then at that point I would ask if there is any member responsibility ( the amount you would be responsible for), if it doesn't match the amount you're being billed from the place you had the xrays done at, then your next step would be to contact them and explain to them that you just got off the phone with your insurance company and they said you should have to pay only $$$. And from there you should be able to create a dialog to get it resolved.

If for some reason the insurance company can't find the claim, which is quite possible if the billed amounts don't match what your bill says and/or the hospital/doctor never sent the claim. Then the next and final option is just to call the hospital/doctor and tell them you already call the insurance company and they have no record of the claim/bill, and ask them why you are still getting statements...Sometimes they'll tell you they did bill but they got a denial and so now they are billing you. Most denials that I've seen where it's not the provider's fault, range from the patient not completing a questionnaire; the two most common questionnaires are a coordination of benefits questionnaire, and or a accident questionnaire. This is just a game the insurances like to do to delay their payment, but after awhile the hospital has no choice but to bill the patient for the whole amount until resolved. I can see if you were injured on someone else property or at a skating rink or something the insurance sending this type of questionnaire to you. Did you happen to get any type of questionnaire from your insurance company? In a nut shell, when talking to the hospital/doctors billing office I would just sound like you are really trying to resolve the bill and want to be helpful, but because you don't have all the info you aren't getting anywhere being in the middle of everything etc etc, and see if they can help you resolve things as soon as possible. They may even be able to do a 3 way call with your insurance company there is conflicting information on the amount you owe.

BUT just to let you know before you do anything you will want to make sure you know your plan fully. A lot of times, I would get phones calls from many patients saying they shouldn't owe anything the insurance should have paid this. When in fact the insurance did pay but there was still a member liability. It's really rare the insurance company will pay film in full, even with the deductible met. There usually is still a coinsurance and at the very least a copayment. With that said the billing services for medical facilities can and do make tons of errors, sometimes they forget to write off a contractual allowance, or even charge instead of credit. If you know how things should be paid its a lot easier to pin point who made the mistake. And mind you insurance companies make a lot of mistakes too.

Good luck I hope you get this resolved, its such a hard thing to understand when you don't understand how things work. I hated my job at the hospital, but was so blessed to have the knowledge on how to resolve things like this At any rate, I wouldn't wait too long to get this resolved, these days they are very quick to send to collections, and you definitely DON'T want to deal with a collection agency they are the pits.

Any questions feel free to msg me. Sorry so long winded hope this helps. but the bottom line is they can bill you until paid. I think in CA the statue of limitations is something around 7 yrs. Although if its been over a yr and you put up a big enough stink you probably can get the bill waived.

take care
amy

To answer your question, they can bill you now, but the insurance coverage is based on the date of service, not the date the bill was generated or received. You received treatment in 09 and those bills should be applied to your 09 insurance. Had you met your deductible when you received the treatment in June? If you had, you need to call your insurance company and insist that they correct this mistake and retroactively apply the 09 claims to your 09 insurance. If you had not, those bills would have been applied to your deductible and you would be responsible for them.
Good luck.

Hi. Insurance is frustrating! I've managed a billing dept. in a multi-doctor office for 10 years and 3 previous years of billing in another office. Two issues come to mind when reading your post. First, if your insurer has a "late filing clause" and your provider is contracted with our insurer, your bills should be marked as "provider liable" on your explaination of benefits/payment (often referred to as an E.O.B. or E.O.P.). Secondly, your date of service is what matters for payment, or application to a deductible, not date of receipt of bills.
If your provider isnt helping you out with this, call your insurer yourself and sort it out. When your provider calls they get Provider Service Department, you get Customer Service Department. You have more power...you pay them :)
BTW any chance your policy is an out of state BlueCross/Blue Shield? Notorious for problems of this type in CA as in most states they are one Company....unlike here in California.
Good luck!

They should go by the date of service, not the date of the bill. Fill out a claim form with your insurance company, or call them and talk to a person (not machine) about why the visit was not covered. If you still have problems, contact your local insurance commission

Soirry for your situation. I know that one of the insurance companies here in Kansas have up to eightteen months to bill for services rendered, thru the state. Some companies pattern their billing practices, similar to that of the state's, for consistency. Call your insurance commissioner in your state, explain your situation, and inquire if his or her office could be of assistance to you in any fashion. Take care, Cindy

I have seen things take a while so I'm not surprised. I've had my doctors office bill the wrong insurance in the past and when I called to let them know they rebilled the correct insurance and it was taken care of.

I recently got a "this is not a bill" invoice from my insurance for a doctors visit from 2008 that the doctor had just billed to the insurance company. The notice stated that the charges due are denied due to how old the original charges were and that I am not responsible for the bill either. We will see if I get anything from the doctors office. I have not received anything yet.

Hi S.,
I see you have had a lot of responses,so mine will probably be the same BUT>>>>
It should be included in last year...the insurance ALWAYS use's the date of injury,on any claim. I deal with insurance companies all the time and the DATE OF LOSS/INJURY id the date they would use.IF this injury was last year,it should not matter WHEN you rec'd the bill, the injury & service's rendered were within your deductible period. Contact the insurance co, not they billing company.
Hope this helps...
Lisa

They still can't change the date of service. Your insurance has to go by that, and don't make the mistake of not having it get paid by the insurance after one year, then they aren't responsible, or so I have been told.

Amy's post is spot on. I worked in billing for years. Because you fell on commercial property, they are most likely looking to see if someone else is responsible or if you are suing the skating rink, so these delays are normal in this case. But keep on top of it, take the bill and contact the insurance, make sure they have been billed, if not, ask if you can fax the claim office the bill. Ring a lot of bells so you can get this covered by them, because ulitimately it is your responsibility to pay, not the insurance company's. In some cases, you may have to pay and look to the insurance to be reimbursed. All doctor's bills are the responsibility of the patient, always, that's why you always need to know how much something will cost, not just think the insurance will pay, so you know how much you may be on the hook for, most people don't realize this, they just get everything done and think it's the insurance's responsibility. If you keep up, I'm sure it will all work out and be taken care of, just stick with it. Have a great day.

If he accident happened last year it should be covered by your insurance for last years deductible. You need to call the hospital/dr. office and find out why they took so long to send the bill. And talk with your insurance and let them know what's going on. You should not have to pay these bills.

they can bill it late.. but it should have the date of when you were seen. call the insurance co.. and let them know that the bill was late.. but the date of the time you saw a dr. was last year.. it should go towards last years bills.

I used to do medical billing as well and I completely agree with Monica. The only other thing I would add is do not give up. Insurance companies are notorious for denying denying denying. They want you to give up and just pay them. Don't let them win. Just keep at it. As long as you are actively "working it out" they can not do anything to come after you. Good luck!

Greetings S.,
We went through this with my husband before his death. I sat down with the billing people of the office and had THEM make calls and do the footwork. If it was their error then NO you don't have to let them get away with this. If you have the original bills / or have the doctors office staff print them up and give them to the insurance company. It may turn out like with us the staff was rotten and had not gone their job properly. Good Luck

Call your insurance. My understanding is these should be covered under the previous year. The date of treatment determines the term of insurance coverage not when you receive the bills.

Call the office that billed you and see if the insurance company kicked it for some reason. I don't think they should be billing you that late, unless the office has been fighting with the insurance company. Which can take a while!

I had issues when I delieved my second son... you see the insurance company kicked all my prenatal & delievery bills because they thought they were being billed twice. I had boys in June 05 & June 07... who ever got the bills say the doctor who was billing was the same, it was at the same hospital, and for a boy born in June - but didn't look at the year... kinda stupid mistake in my eyes, but it took me over 2 months to find someone who would talk to me about it & finaly did accept the bills and pay for them THANKFULLY - cause it was a big bill which I couldn't have paid out of pocket for.

I wish you luck in your battle with the insurance company!!! But I would call who ever bill for the x-rays & try to find out why they billed you so late. Then go from there.

If the bill was incurred during the period for which you have met your deductible, then the insurance company should pay it. It's not when you get billed, but when you had services that controls.

To the best of my knowlegde, the deductible is based on the "date of service", not the invoice date. Different states have different regulations, but in most cases the billing has to be done within a certain amount of time, and the insurance company has to act upon it within a certain amount of time. Six months is not unreasonable.

Make sure you pay your portion (what you believe you owe). Write a letter to your insurance company attaching the bills, and send a copy to the provider. See what type of response you receive.

each bill should have a "dob"--date of service. If this service was done say 10 months ago, they shouldn't be paying it now... by the way, there is a deadline for these people to submitt this sort of billing it's usually 90 days from date of service. Are you sure they are not just explanation of benefits--not an actual bill but a statement? call your insurance company, let them explain it to you as well.

You are still covered by last year's insurance because the claim was last year. Tell the doctors and other providers to bill your insurance.

It should still be covered under last years deductible - It doesn't matter when they bill it, it matters the DATE OF SERVICE....so you need to submit it to your insurance and they should cover it under last years policy. Hope that helps -