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I have a Dr. Bill for $2600 and my insurer is only paying $358


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All,

 

Charges incurred from ER visit for extreme abdominal pain. I was admitted on 9/1/2014 and discharged on 9/4/2014. I have 9 line items on my bill from the Dr. CareFirst BlueChoice is refusing to pay 3 of the line items because they were incidental to a Primary service on the same date.

 

On the other 6 line items the amount the doctor billed for was more than the maximum payment CareFirst allows. The $358 is the total amount that CareFirst normally allows for those items. When I spoke with the medical biller she said this Dr does not have an agreement with Carefirst. When I called Carefirst they said they are only going to pay the amount they normally pay for that line item.

 

From my point of view, I was in the Emergency Room. It's not like I could say no I don't want to see the Dr. on duty. In my opinion if the doctor didn't sign up to be part of the Carefirst plan I shouldn't have to pay the difference. If I had known this I would have asked for a doctor under my plan but that is really ridiculous to expect someone to do.

 

Anyone have any suggestions? I know some of you have been through this before. And the medical biller said she would not send this to credit but I am thinking I should send her a certified letter informing her I am disputing this bill just to have on paper where I told her I am disputing the bill? Is that a good idea? Anyone else been through this before where their insurance is not paying the amount the doctor billed?

 

My 1st step is disputing with my insurer

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Get your EOMB ( explanation of medical benefits) from your insurance Co.

 

This should show the billed amount THE APPROVED AMOUNT your deductible or co-pay amount and the amount you are obligated to pay.

 

If the Dr accepted whatever payment he received from your insurance he was obligated to accept their approved amount.

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Hi WhyChat. The approved amount adds up to $358. The doctor already asked me to forward them the check from my insurance company but I didn't know if I should send it to them yet or not.

 

I understand you say they are obligated to accept the approved amount but that is not spelled out anywhere is it? My doctor definitely is not part of the Carefirst network so do not think they are obligated to accept the approved amount. I was thinking I would send them this check, then they will come after ME for the remaining amount.


Carefirst sent me the check and told me to forward to the dr

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If the check is made out to the Dr and you forward it to him along with the EOMB and a cover letter stating that this is payment in full for the medical service, and you send it to him REGISTERED MAIL, and make copies of the check and all correspondence, unless he returns the check to you, his acceptance prevents him from "balance billing" you legally. If the EOMB states that you are liable for any deductible or co-pay, get a BANK MONEY ORDER for that amount and send it along with the check from the insurance Co. Make copies of everything (front and back of checks). On the back of BOTH checks in the endorsement section, write- "for deposit only acct. of (name of Dr.)"

 

 

Meantime follow the guide:( just in case you need to take further action)

http://www.whychat.5u.com/GUIDEBOOK.html

Edited by Why Chat
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Hello,

 

Thanks for the response. The check Carefirst sent is made out to me, and they said I am responsible for the remaining balance. The EOMB says my deductible is already satisfied.

 

In this case how should I proceed? I am guessing that I could write Pay to the order of Dr. XXX on the back of the check, and add a Cover Letter stating this is Payment in Full for the services provided by Dr. XXX's office. And send it all Registered Mail (Is that different from Certified?)

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Send it with this:( yes endorse the back of the check with your signature and for deposit only account of Dr. X)

Registered mail is different than certified mail ( somewhat more expensive)

 

Enclosed please find my remittance of $358. for payment in full of this account.

 

This payment in full is for services as per the attached EOB from XXXX XXXX)

 

Please note, my remittance is payable ONLY to (hc provider) and may not be signed over or transferred to any third party collection agency, as this would constitute a violation of HIPAA, State Privacy Act rules and the Omnibus Final Rules.

 

Your furnishing of my account information to any collection agency, would not be in compliance with HIPAA,, and any subsequent reporting of this account on my credit reports to any credit reporting bureaus would be a violation of Public Law 104-191 ("HIPAA") since there can be no permissible business purpose in divulging protected health information to anyone on an account once there is no longer any payment due

 

.In addition the new Omnibus Final Rule states:when patients pay out of pocket in full, they can instruct their provider to refrain from sharing information.This letter serves as that instruction

 

Copies of this correspondence and a copy of the remittance check may be used for any further actions with State or Federal agencies

Edited by Why Chat
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Thanks WhyChat!

 

 

I'll post updates as well

Cause I have no clue how I am going to get out of paying the extra $2300

Well, if you send the letter I suggested, it doesn't prevent them from BILLING you for the balance, however it DOES serve to prevent them from turning the account over to a CA.

 

 

 

Your furnishing of my account information to any collection agency, would not be in compliance with HIPAA,, and any subsequent reporting of this account on my credit reports to any credit reporting bureaus would be a violation of Public Law 104-191 ("HIPAA") since there can be no permissible business purpose in divulging protected health information to anyone on an account once there is no longer any payment due

.In addition the new Omnibus Final Rule states:when patients pay out of pocket in full, they can instruct their provider to refrain from sharing information.This letter serves as that instruction

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