State Law Barring Patient Billing If Insurance Filed Late

[HoustonLynne]

I see this come up a lot with medical collections, and other states may have a similar statue in place. This is probably already posted somewhere on CB, but I just ran across a Texas law that indicates a patient cannot be billed if the provider fails to file a claim with their insurance provider in accordance with said law. (See last subsection, § 146.003. Certain Claims Barred)

 

Tex. Civ. Prac. & Rem. Code § 146.001 (2000)

 

§ 146.001. Definitions

 

In this chapter:

 

(1) "Health benefit plan" means a plan or arrangement

under which medical or surgical expenses are paid for or reimbursed or

health care services are arranged for or provided. The term includes:

 

(A) an individual, group, blanket, or franchise insurance policy,

insurance agreement, or group hospital service contract;

 

(b ) an evidence of coverage or group subscriber contract issued by a

health maintenance organization or an approved nonprofit health

corporation;

 

(C ) a benefit plan provided by a multiple employer welfare

arrangement or another analogous benefit arrangement;

 

(D) a workers' compensation insurance policy; or

 

(E) a motor vehicle insurance policy, to the extent the policy

provides personal injury protection or medical payments coverage.

 

(2) "Health care service provider" means a person who,

under a license or other grant of authority issued by this state,

provides health care services the costs of which may be paid for or

reimbursed under a health benefit plan.

 

§ 146.002. Timely Billing Required

 

(a) Except as provided by Subsection (b ) or ©, a health care service provider shall bill a patient or other responsible person for services provided to the patient not later than the first day of the 11th month after the date the services are provided.

 

(b ) If the health care service provider is required or authorized to directly bill the issuer of a health benefit plan for services provided to a patient, the health care service provider shall bill the issuer of the plan not later than:

 

(1) the date required under any contract between the health care

service provider and the issuer of the health benefit plan; or

 

(2) if there is no contract between the health care service provider

and the issuer of the health benefit plan, the first day of the 11th

month after the date the services are provided.

 

(c ) If the health care service provider is required or authorized to directly bill a third party payor operating under federal or state law, including Medicare and the state Medicaid program, the health care service provider shall bill the third party payor not later than:

 

(1) the date required under any contract between the health care

service provider and the third party payor or the date required by

federal regulation or state rule, as applicable; or

 

(2) if there is no contract between the health care service provider

and the third party payor and there is no applicable federal regulation

or state rule, the first day of the 11th month after the date the

services are provided.

 

(d) For purposes of this section, the date of billing is the date on which the health care service provider's bill is:

 

(1) mailed to the patient or responsible person, postage prepaid, at

the address of the patient or responsible person as shown on the health

care service provider's records; or

 

(2) mailed or otherwise submitted to the issuer of the health benefit

plan or third party payor as required by the health benefit plan or

third party payor.

 

§ 146.003. Certain Claims Barred

 

(a) A health care service provider who violates Section 146.002 may not recover from the patient any amount that the patient would have been entitled to receive as payment or reimbursement under a health benefit plan or that the patient would not otherwise have been obligated to pay had the provider complied with Section 146.002.

 

(b ) If recovery from a patient is barred under this section, the health care service provider may not recover from any other individual who, because of a family or other personal relationship with the patient, would otherwise be responsible for the debt.

Edited April 29, 2014 by HoustonLynne

[Why Chat]

This is standard in all States, however it is a "toothless tiger" as the OCs frequently state that they DID submit to insurance, or that the patient did NOT provide them with their insurance data.

 

A much better statute ( and one on which some of the HIPAA letter program is based), is in all State's statutes, ( although it may be difficult to locate) and adheres to the Federal laws that require all health care providers to accept cash payments for services. This law was intended to outlaw those health care providers who refuse to treat patients without insurance or credit cards. That is why in the HIPAA letter program if payment is to be made to an OC it must be in the form of a BANK money order, which is legally the same as cash and can not be refused.