Health Insurance Blame Game – Stuck Between Insurance Company and Doctor’s Office

October 13, 2007

Do you ever feel like navigating the health insurance claim process is like walking through a maze blindfolded?  Our most recent experience leaves me wondering how many people get stuck paying hundreds of dollars for claims that should have been covered.

During a recent visit to the pediatrician the receptionist informed my wife we had a balance of over $300 outstanding. Luckily she only paid the co-pay and got the phone number of the billing department so I could call and investigate.

Doctor’s Office Perspective
When I spoke with billing the next day, they informed me that the claim they had filed with our insurance company for a visit from December of last year had never been processed.  They started off by sending an electronic claim and after receiving no response they sent a follow up by either mail or fax.  When no response was received the doctor’s office then billed us directly.

Insurance Company’s Perspective
Having heard the pediatrician’s side of the story, I then called the insurance company to see what went wrong with the claim.  According to little miss phone rep the doctor’s office hadn’t submitted the necessary paperwork until April of this year, past the 90 day window stated in the contract between the doctor’s office and the insurance company.  According to the contract, since the pediatrician had waited too long to submit the claim, the insurance company was not liable for the charges and had sent the doctor’s office a letter informing them of this.

Patient’s Perspective
I pay my health insurance premiums monthly and a fork over a co-pay at every doctor’s visit; I’ve upheld my end of the contract.  I expect the insurance company and the doctor’s office to run their business correctly. I shouldn’t have to be stuck in the middle of the two parties trying to negotiate an agreement.

When the doctor’s office joins the insurance company network, they agree to follow certain procedures and the insurance company takes on the obligation to process claims effectively and efficiently.  It sounds as though the claims process is not perfect and could use some revising.  If the system is broken, they should do something to fix it, not leave the customer stuck with a bill.

Stuck in the Middle
When I spoke with the women in the pediatrician’s billing department she said this type of thing happens all the time.  In my conversation with little miss phone rep from the insurance company she informed me this type of thing is rare.  Obviously the two answers don’t match up.

The insurance company advised me to ask if the doctor’s office had any proof that they had sent the claim within the 90 day window.  If not I should tell the pediatrician I wasn’t liable for the payment and if they gave me grief to let the insurance company know. 

The only positive in the experience is that my wife didn’t pay the over $300 bill when she was at the doctor. I’m sure if she had we would never have seen the money again.  However, I’m not looking forward to the nasty arbitration I imagine I’ll have to direct to resolve the issue.  Does it really have to be this difficult?


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Ben Edwards, the founder of Money Smart Life, saved up enough to buy a Nintendo back when he was 12 years old. When he used the money to buy shares of Wal-Mart stock instead, he knew he wasn't like the other kids... His addiction to personal finance has paid off for his family and now he's helping you to afford the life that you want. Check him out on the web at Google Plus, Twitter and Facebook.

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8 Responses to Health Insurance Blame Game – Stuck Between Insurance Company and Doctor’s Office

  • Ben

    Danusia, sorry to hear they’re sending you to collections. As you mentioned, you have to be careful with that situation because it could impact your credit score.

    If I were you I’d call the insurance company and get the details on why they won’t cover the procedure. Every insurance company/policy has a ton of rules on what’s covered and what’s not and in what circumstances. I’d find out specifically why they won’t cover it and check their answer against your policy to see if they’re just trying to wriggle out of paying.

    • Juliei

      I just had similar situation occur. The doctors office and the insurance co usually have a legal agreement if the doctor’s office is a participating Doctor with your insurance co. If so you can Call the insurance and tell them the Doctor office is harassing you about payment and could they do something about it. Isn’t there agreement between the two of you? Doesn’t the agreement state the Doctor office is not suppose to bother you with issues that are between office and insurance..If they do have agreement part of that is they cannot send you to collection if insurance is responseable for payment. If doctors office didn’t send his claim on time it is their problem. My insurance sent a letter for me getting the doctors office off my back but they only did this when I asked them to. Just to let you know if insurance pays them and it is less than Doctor wants they cannot bill you the difference if the Doctor is in there network (HMO) This is illegal it is double billing but it is done all the time.

  • Danusia TREVINO

    I am in a similar situation, a urologist sent me for a procedure to a hospital. Every place I was asked for my insurance card. Now the hospital is sending me the bill saying the insurance refuses to pay. I keep talking to both parties to no avail. The last letter i got was a treat to pass me unto collection agency for $400. I am really frustrated that i need to spend time on this and don’t want to have a bad credit.
    i don’t have 400 to trow away for something that the insurance should pay, that’s why I have the insurance in the first place. I called my husband’s union and they told me not to worry but i keep getting the treats.

  • Jerry

    My first inclination is that the insurance company is out to red tape you into submission. That’s not always the case. Sometimes the billing office makes errors, as in your case, and it leads to confusion and unnecessary hold ups.


  • winona

    I’m in a similar situation as you right now and it’s not uncommon. Years ago, I had a dispute with my Health Insurer. I sent several letters, all of which somehow never got into my file. Finally, my company had to step in. Now I’m fighting another payment denial and coincidentally, so are my boss and another co-worker. It won’t stop until the government steps in because they’re just too powerful against us individuals. Health insurers care about one thing and one thing only: the bottom line.

  • bill

    At the doctors office, if you signed some sort of financial responsibility form, which most have you do, you may be on the hood for the 300 dollars.

  • Scott

    I would be surprised if there is ever any arbitration. The arbitrator’s fees would be more than $300.

  • shadox

    This is ridiculous. I would tell the doctor’s office to resolve it directly with the health insurance and suggest that they submit documentation that they filed on time. This is really not your problem and the two companies should resolve this on their own.

    This is one small symptom of the ridiculousness of the American health care industry. The health insurance situation in this country is way past normal. It’s about time Washingtom got off their butts and did something meaningful to address the entire problem.