AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? What are fee schedules and are you
responsible to pay them? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible?
If you have these questions or others on why your insurance company is
not paying your bills, I can help. I can give you "tricks of the trade"
to get your insurance company to pay.
Experience In the medical field for over 18 years spending majority of time in the collections aspect.
Question I had an accident while vacationing in a new city and had to get stitches. We ended up in ER but due to a long wait decided to call our Insurance BCBS and get an in-network urgent care, the customer service representative directed us to one. At the Urgent care we did the paper work, paid our in-network copay and got treated. 2 months later the Urgent care called to say the Insurance refused to pay. When we called up the Insurance they said they were not contracted with them anymore...having done my homework, I pointed out to them that the urgent care was listed as in-network on their website even as we spoke.. she was confused and said would get back...this has been going on for 2 months, each time we call they say the same thing that they were not contracted with them at that time..and we ask them the same question "why were we sent there then? Finally BCBS decided to look up the transcript of our conversation on the day of my injury, and verified that indeed they had given me the wrong information, their website is not updated on a daily basis and the CS Representative gave me that information but it was my responsibility to check with a provider when I walk through their doors if they are in-network or not, hence they are not responsible as they have a disclaimer on the website that this information my not be up to date, even thou' I wasn't the one using the website. I agree that I did not check with urgent care since I was sent there by BCBS in the first place and with a broken forehead I did not think about that.
I called up the Urgent care to verify if they were or not contracted with them during that period? and they said that they were new, the contract had not started but they were accepting all patients and billing the insurance and some insurances were paying, all this was in the paperwork that I signed. They did not tell me upfront that I was out of network, they took my insurance card, the paperwork and charged me my standard in-network urgent care copay... I think both the Insurance company and the provider were at fault here. The Urgent care has offered to reduce the payment for me significantly but I haven't found out how much. What are my options, please advise..
Answer Hi Swati!
I think BC should take the "bullet" and pay the Urgent care center as an exception which they do all the time.
Their employee told you the wrong information so why would you not trust what they said.....so they should pay due to wrong information given to you.
So I would do an appeal......when you get a denial letter you will have information on that letter that tells you how to appeal and where to send the appeal. An appeal is just a chance to voice your rights and tell them why you feel they should pay this claim. You have valid reasons so appeal their denial to see if they will reverse their denial and pay.
Make certain in your appeal letter you stress the fact that they "made the error" and "why would you question their employee", etc etc.........put all the blame on them for THEIR error and cc perhaps your attorney or the Insurance commissioner in your state. Also send it certified mail-----it sort of shows you mean business.
I would not pay even a discounted bill at this point, not prior to the appeal.....
