Doctor Didn't Bill Insurance

by Adrien
(Sugar Land, TX)

When a medical care provider failed to submit claim for reimbursement in time (about a year), and the claim is subsequently rejected by the insurance company for that reason, can the doctor come after patients for unpaid service? The patient provided all correct insurance information and the doctor would have got full reimbursement if they filed the claim in time; however, they forgot about it for a year and now the insurance company wouldn't pay. What's the patient's right and protection? Thank you.

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Jul 11, 2011
Texas Medical Billing Statute
by: DebtCollectionAnswers.com

The Texas Civil Practice and Remedies Code Chapter 146.002 says:

Sec. 1301.102. SUBMISSION OF CLAIM. (a) A physician or health care provider must submit a claim to an insurer not later than the 95th day after the date the physician or provider provides the medical care or health care services for which the claim is made.
(b) Except as provided by Chapter 1213, a physician or health care provider may, as appropriate:
(1) mail a claim by United States mail, first class, or by overnight delivery service;
(2) submit the claim electronically;
(3) fax the claim; or
(4) hand deliver the claim.
(c) An insurer shall accept as proof of timely filing a claim filed in compliance with Subsection (b) or information from another insurer or health maintenance organization showing that the physician or health care provider submitted the claim to the insurer or health maintenance organization in compliance with Subsection (b).
(d) If a physician or health care provider fails to submit a claim in compliance with this section, the physician or provider forfeits the right to payment unless the failure to submit the claim in compliance with this section is a result of a catastrophic event that substantially interferes with the normal business operations of the physician or provider.
(e) The period for submitting a claim under this section may be extended by contract.
(f) A physician or health care provider may not submit a duplicate claim for payment before the 46th day after the date the original claim was submitted. The commissioner shall adopt rules under which an insurer may determine whether a claim is a duplicate claim.

Jul 11, 2011
Medical Provider Slow In Billing Insurance
by: DebtCollectionAnswers.com

It's a good thing you live in Texas! We consulted with Mark Rukavina of The Access Project and he helped us with the following information:

First of all, providers are often bound by their contracts with private insurers. When the patient is seeing an in-network provider, it is often the case that the contract would not allow them to bill the patient if the claim was denied because it was not submitted within the specified time frame.

In addition, however, Texas has a consumer protection law that applies here.

Under this law, if a PPO or HMO does not bill the insurer on time, then they forfeit the right to payment. This includes payment from the insurer and/or the enrollee. Given this, the provider should NOT be going after the patient for payment. I would recommend your reader contact the Texas Department of Insurance directly and consider filing a formal complaint with them (cc-ing the TX Attorney General generally doesn't hurt, either).

You can also request assistance through the:

Texas Consumer Health Assistance Program
1-855-TEX-CHAP
(1-855-839-2427) toll-free
Monday through Friday,
8 a.m. to 5 p.m., Central time
http://www.texashealthoptions.com/cp2/cpmchap.html

The Texas Consumer Health Assistance Program can help you:
- Learn about your rights under federal health care reform and state law
- Enroll in a health plan, including the Pre-Existing Condition Insurance Plan (PCIP)
- Appeal a health plan's denial of a treatment or service
- Resolve a complaint against your health plan or insurer
(emphasis mine)
- Obtain the health care premium tax credit (for small businesses)


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