r/HealthInsurance • u/JulesSherlock • 4d ago
Medicare/Medicaid Anesthesiologist is billing $3700 even though insurance is telling them to stop.
My husband went to the emergency room due to food blocking esophagus. He had to have a gastroenterologist, push it on down. The anesthesiologist billed his insurance who refused it based on it being filed too late. Procedure was 3/8 and they billed 7/1. Then they billed him $3700, which is when he noticed the issue. Said insurance paid $0 and if he didn’t pay by 9/15 it would go to collections. He called his insurance (United Healthcare - Medicare) and they said they would call them the next day and have them refile it. He watched for it online and saw that it had been re-filed on 8/1 so he thought it was ok. Well, insurance denied it again. It says denied due to filing too late and do not bill member. Same as last time. So he expects to get a bill in the mail any day now.
I feel like we’re going in circles. How do we get off this ride if we do get the bill again?
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u/wistah978 4d ago
Assuming they were in network, timely filing is the responsibility of the provider. You should have an EOB showing your responsibility is $0. The EOB will also likely say something to the effect of they cannot bill you. Ask the office for a fax or email and send them the EOB. I would say that because they are threatening collections so soon that you are requesting an email confirmation within 3 business days that you are not responsible for the bill so that you have time to notify your state's insurance commissioner. (Who may not be able to do much but should get their attention.).
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u/EamusAndy 4d ago
It is not your husbands fault the provider didnt bill timely. Thats on them.
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u/Whole_Bed_5413 4d ago
Interesting that physicians get months to file claims, yet insurance companies get years to claw back a retroactive denial. Right. It’s the physician’s fault. And what does the insurance company have to lise when the physician files later? Nothing. They get to hang on to money that they owe, interest free.
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u/TheGreatAlibaba 4d ago
Providers have 12 months (so there's something else going on here), which should be more than enough time. And that's the initial billing, so if things are wrong and they need to be corrected, the clock restarts to the day the billing was processed. At least is Medicare.
And I have no problem with that. Providers shouldn't be allowed to wait years to bill either party.
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u/LamentForIcarus 4d ago
This isn't true for all carriers. I have one Medicaid MCO that wants a claim within 60 days from DOS, though most usually do 90 to 180 days. This is theoretically enough time except a lot of places are understaffed so it can get backed up. Also, in my experience corrected claims are just as often from DOS as processing.
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u/TheGreatAlibaba 4d ago
You are absolutely correct that it's different for Medicaid and other types of insurance. But this specific situation is Medicare and the 12 months is a CMS guideline. So all Medicare plans have that as a minimum.
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u/megan8086 3d ago
It sounds to me like if UHC MCR Adv is denying for timely twice within 5 months, then the anesthesiologist is OON. Which is crappy if he was being used by an IN facility and surgeon. I haven’t worked government contracts in a minute, so I don’t remember what the guidelines are for billing a patient for OON when all other providers involved are IN.
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u/JKTX30 2d ago
Wouldn't this fall under no surprises because it was an emergency?
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u/megan8086 2d ago
So, based on what I’m reading is that some provider contracts with UHC Medicare only allow for 90 days timely filing for In Network providers and 180 days for Out of Network providers (used to be 365 days across the board following Medicare guidelines). If this is the contract language the anesthesiologist has, then a timely filing denial at four months would indicate the provider is in network and MUST accept the claim’s processing. That would mean, according to the EOB, the patient cannot be billed. Period. If your provider is OON, neither claim would have denied for timely filing since they were both received by UHC before the 180 day deadline. The No Surprises Act would not apply on your specific claim because the claim was denied for timely filing and the provider has to adjust the entire claim amount, so there’s no “balance” that could potentially be billed. NSA comes into play when you’re seen by an OON provider in an emergent case and the claim is processed and paid by the insurance company - they bill $1000, insurance company pays $500, balance of $500 COULD be billed to patient since provider is OON but since it was emergency services the NSA kicks in and prevents you from getting that $500 balance bill. I would question the anesthesiologist’s billing office (calmly) as to why you’re receiving a bill when UHC says there is no patient responsibility. That’s really what it boils down to at this point. If they still insist on billing you, submit the bill and your EOB to UHC. They’ll usually handle it from there on behalf of the patient (but definitely follow up with both dr’s office and UHC regularly until it’s resolved - don’t ignore any bills). Make payment arrangements ($25/month if you can should be sufficient) to prevent them from sending you to collections in the meantime. Once it gets straightened out, if you’ve paid them money, they’ll owe you a refund.
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u/JKTX30 2d ago
Okay, so basically with this situation we never even get to the point where NSA would come into play. Because the bill itself is invalid so why should they make payments on it? Even if it was sent to collections, the collections wouldn't be valid either.
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u/megan8086 2d ago
Agree one hundred percent: the bill is not valid. However, if the billing dept is particularly irresponsible or something and whoopsie! sends the account to collections, it could hit your credit. I just feel like that’s a whole new can of worms restoring your credit once the bill itself is resolved. Sure, the dr’s office will retract the collections account but then it’s on you to follow up with the credit bureaus to make sure the erroneous account is removed from your credit report. It’s obviously completely up to the individual patient as to how to handle the situation, but for me personally, if I’m able to afford it, I’d rather make the absolute minimum payment necessary to keep an account out of collections - too many horror stories about shady third party collectors buying debt that was resolved but not removed from a report and restarting the collections clock.
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u/Puzzleheaded_Serve37 3d ago
Not all providers have 12months. A lot of newer provider contracts I’m seeing are giving 60/90/120 days to submit. Unless state law requires longer.
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u/TheGreatAlibaba 3d ago
Federal law requires longer for Medicare. Non-Medicare plans are certainly different.
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u/Puzzleheaded_Serve37 3d ago
I’m assuming that this is a Medicare secondary not MedAdvantage hence the short timely filing period.
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u/megan8086 2d ago
I thought the same, but from what I can see in the UHC provider manuals, they are stating to refer to your contract for timely filing limits even for the Advantage plans. I wonder if there’s a difference between HMO, POS, and PPO plans. I have been out of the Medicare billing loop for a minute - working commercial payers for the last few years.
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u/ProfessionalYam3119 2d ago
Some plans are 90 days. And everything hinges on whether they're in network.
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u/nestchick 4d ago
When I was a claims examiner I discovered we had been overpaying dialysis claims, but we only looked back 2 years when seeking reimbursement from the providers. I found $177K worth of overpayments. Did we collect all that? No. The results of my review were sent to provider relations to negotiate settlements. No way did we get the full amount back. So I am not sure where you got “years” regarding retroactive denials. Kindly show your math. ( And yes I know two years is “years “.)
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u/LamentForIcarus 4d ago
I have a client who is constantly fighting with Aetna for retroactive denials and recoupments despite their contract specifically stating the carrier only has 18 months, but I have seen recoupments from as old as 5 years ago. It's absolutely ridiculous.
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u/MountainFriend7473 4d ago
Ran into that for BCBS not long ago, apparently they were messing around with things years back (5+ years) and done asking to pay up after having covered it previously. But BCBS is not always nice about oncology coverage and such
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u/Whole_Bed_5413 2d ago
What are you even talking about with your anecdotal evidence of maybe one company (if you are veing accurate). And by the way, the people nsyrance company obviously paid these claims you speak of and “overpaid” is relative considering that most insurance companies pay a fraction of market rate and an even smaller fraction of charges.
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u/EamusAndy 3d ago
You realize its actually the State that claws back claims retroactively right? And they have 7 years. Dont blame MCOs when it takes them seven years to do the due diligence that weve been telling them to do since 2018.
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u/Whole_Bed_5413 2d ago
Where did you learn insurance law? No. You’re 100% wrong. The only time that the state would be clawing back ANYTHING is if the patient was a Medicaid beneficiary or the state was otherwise funding the patient’s medical care.
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u/stuckhuman 4d ago
Don't pay. They failed to file timely. It's on the anesthesiologist. If they take it further, it's lawyer time.
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u/Few-Consequence-124 4d ago
This. The provider’s billing mistakes are not your husband’s responsibility. If they have the moxie to bill you again, call UHC and file a grievance. As part of the grievance, ask them to send a Cease and Desist letter.
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u/milkpickles9008 4d ago
If the anesthesiologist is an in network contracting provider with your insurance and they missed the timely filing period to submit the claim then do not pay that bill. It sucks, but just keep talking to your insurance company. Have them escalate it if the rep has any power to do that.
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u/LividLife5541 4d ago
lmao it sucks being charged thousands of dollars months after the fact because doctors can't get their shit together. They literally pay people to do this for them. This isn't some arcane financial number that takes a KPMG audit to provide. It's a medical service they do on a weekly if not daily basis and for which the billable costs have already been negotiated.
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u/Long-Raccoon2131 4d ago
First is the provider in network? If not they aren't obligated by a contract with the health plan to not bill. Also at the ER did you fill put forms one of which thet call patient responsibility form? That form ks a legal document stating you agree to pay anything not covered by insurance. Now is Medicare the only plan? Because if there is a primary policy and Medicare is secondary then primary deductible and out of pocket trump secondary billing
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u/Fin-Tech 3d ago
What about the No Surprises Act? I'm thinking if the ER was in-network but the anesthesiologist wasn't, then the advantage plan is required to pay and the anesthesiologist is prohibited from balance billing under the NSA. Am I mistaken?
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u/Long-Raccoon2131 3d ago
That ACT doesnt mean what many think it means. It means you cant be surprised with a bill ypu acknowledge and consented to. The No Surprises act is for when you cant make a decision and are air lifted or sent by ambulance to a non participating network hospital. If you went there yourself you signed cornet forms and patient responsibility forms.
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u/AgreeableCoconut2037 3d ago
This is completely incorrect. Not only does the No Surprises Act mandate in-network coverage for emergency services at OON facilities (regardless if you choose the ER yourself or if you arrive via ambulance), it specifically bans balance billing for OON ancillary services like anesthesiology when services are not emergency services but are rendered at an in-network facility.
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u/Fin-Tech 3d ago
Below is an excerpt from: https://www.cms.gov/medical-bill-rights/know-your-rights/using-insurance#emergency-room-care
If your health insurance covers emergency care, you can't be charged any more for emergency medical services than the in-network “cost-sharing” rate by:
The hospital The providers giving you care at the hospital Your air ambulance provider (if you were taken to the hospital in an air ambulance)<end excerpt>
OP's anesthesiologist was a "provider giving you care" and so the NSA would apply according to CMS.
Regarding your point about "can't make a decision," I would argue that a choking patient in the ER does not have effective agency to make any kind of "decision" (much less an informed one) about which anesthesiologist to use if there was even more than one option in the first place. I feel like this lack of transparency and agency is a foundational reason why the NSA was needed in the first place.
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u/cuspeedrxi 4d ago
This is the correct answer. Disregard the one-liners about ignoring the bill. You need to determine if the physician is in-network and if you agreed to pay for charges not covered by insurance.
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u/Ridgewoodgal 4d ago
This is odd since almost everyone else is saying if in-network that it is not the patient’s responsibility. Don’t we always sign a form like that but it isn’t for mistakes made by an in-network hospital.
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u/cuspeedrxi 4d ago
It’s two separate considerations. 1) Is the doctor in-network? If so, he’s bound by the contract he signed with the insurer. If he filed the claim outside of the required window, then you’re off the hook. It’s his error. Though you may need to remind him of that. Don’t just ignore the bill. Circle back and explain why you’re not liable for the bill. 2) Did you sign a patient responsibility form? If he’s out of network, then you have to pay whatever he charges. But, what else does this form say? Any surprises??
Too often people on these subs advise you to “screw ‘em” and leave it at that. Then, bills get turned over to collections and people have a bigger mess of their hands because they ignored the bill or didn’t follow up, etc.
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u/bethaliz6894 4d ago
#3 - Was the insurance card presented in a timely fashion? If they checked in and said we will give the card later and didn't, they can still be on the hook for the bill.
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u/JulesSherlock 4d ago
I think the provider is in network because he had surgery at the same hospital with the same anesthesia provider in January and insurance did pay that bill.
Medicare advantage is the only insurance.
I do not know about the patient responsibility form.
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u/wistah978 3d ago
Contracts change. It is likely but not certain that they were still in network. Check your insurance website for the provider's status.
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u/OkLime225 1d ago
It would say out of network on the bill and in the patient column it would have the full amount. Sounds in network and you are not responsible
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u/JulesSherlock 1d ago
Nothing on EOB or bill says out of network. And EOB states his portion as $0.
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u/JKTX30 2d ago
If it is an emergency, they cannot trick you with hidden "patient responsibility" clauses in the fine print anymore, thanks to the No Surprises Act, whether it is in or out of network. (Of course, you are still responsible for any deductibles and copays that maybe applicable, but emergency care is covered at the in-network benefit level.)
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u/Long-Raccoon2131 2d ago
Emergency means you could not be of sound mind to make a decision therefore whatever treatment is protected by that ACT. If you go on your own free will even if you called for the ambulance you on your own volition enacted the request and it was up to you to understand your plan. Also not all insurance is covered under that ACT either only Medicare specifically and if a states medicaid chooses to. Most marketplace ACA plains abide by it. Yet employer insurance or private bought it does not protect it. EMERGENCY doesnt mean you went to the ER for anything it means you went and had no knowledge of it and you were sent without you asking. This is mostly about air transportation or major accidents where you are unresponsive and they send you wherever
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u/JKTX30 2d ago edited 2d ago
This is incorrect. The standard of an emergency is the reasonable person standard that someone would reasonably believe they are in danger of death or serious impairment of some kind if they do not seek immediate treatment. And the act covers going to any emergency room in that case, whether by car or ambulance or whatever. And the act also covers most all common types of health insurance plans. You can read all the details here and the no surprises act is in fact pretty broad in its protections against surprise billing in emergency (and even some non-emergency) situations. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/avoid-surprise-healthcare-expenses
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u/CatPerson88 4d ago
Your insurance has a timely filing limit of probably 90 days. They work in a participating hospital. They have to abide by the rules as a participating provider. If it's too late to file, they can't collect from the patient.
If they bill him again, call and tell them you know they're not allowed to bill him.
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u/DCRBftw 4d ago
Timely filing denial isn't your fault. The provider has to adjust this bill because they took too long to submit the claim to insurance. If necessary, have a 3 way call with insurance and billing manager, but if the provider has received the denial, they know they have to write it off. Don't pay this.
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u/Old_Draft_5288 4d ago
You don’t need to do anything at this point, if they even try to send it to collections you have clear proof that they failed to bill in a timely manner with the letter from your insurance. You would provide that to collections and collections would have to eat the cost, and you can contest it on your credit bureau.
Filing a complaint with the state medical licensing board is probably a good way to go
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u/bethaliz6894 4d ago
One question, was the card given to the ER the time you checked in? If not, at what point was the card given? This does matter. If the card was not given in a timely fashion, then yes, you can be held responsible.
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u/JulesSherlock 4d ago
It was given while he was at hospital. All others billed without issue - hospital, Gastro doctor.
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u/N2wind 3d ago
Timely filing is a provider issue. They have to eat it. File a complaint with CMS since this is a Medicare HMO. Medicare audits are about the worst thing for a provider as far as billing goes. I have carriers that only allow 90 days for timely filing but some go to 2 years. I have done anethesia and pain billing for over 25 years and you would not belive the providers that think they can balance bill patients due to their previous billing company errors. Just this week I wrote off 3 years of office visits (around 15) for 1 patient because the previous billing company kept billing the wrong insurance and now it is past timely.
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u/JulesSherlock 3d ago
Thank you for the info.
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u/KickstandSF 3d ago
Yes, just call the provider and give them the info from the insurance, and then say the magic words “if we receive a bill, we will be reporting it to Medicare as fraud.” Not much instills fear in a medical office as Medicare fraud. The INDIVIDUAL STAFF as well as Dr and office can be liable.
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u/RicardoNurein 3d ago
No, but he said.... oh no, they said, ... but wait contractual deadlies,... and on and on
State Insurance comissioner
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u/Saturngirl2021 3d ago
He needs to call his Medicare insurance company customer service and request a 3 way with the anesthesiologists billing. I worked for customer service with a Medicare insurance company and the billing company would always immediately say oops the patient owes $0 now. Give it a try.
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u/OkLime225 1d ago
As a medical biller absolutely do not pay this. Your insurance has clearly stated not to bill the patient. Them trying to bill you would be grounds for them loosing their contract. And if it has anything to do with medicare they do not play. Loosing medicare contracts is like basically getting blacklisted.
Get in touch with billing and let them know they need to write this off as their loss or you'll be reporting this provider to the insurance and to the state.
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u/Known_Paramedic_9503 4d ago
If they told them not to build a member, then it was billed back to the hospital not your husband. He is not responsible for it. I just went through this in April.
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u/CrabConsistent9777 3d ago
Something is off here. Did the provider say there was a denial at all? The best thing would be to get on a three-way call with your insurance and provider. An untimely denial for something performed less than a year ago is unusual, but it depends on the plan.
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u/JulesSherlock 3d ago
Their bill just said that Insurance paid zero and we owed the full amount.
So then we looked up the claim on the Insurance site and it said it was not filed in time (timely manner) and do not bill member. And they were paying $0. His responsibility was $0.
Didn’t seem like much time to me, I mean the procedure was March 8 and they billed insurance July 1. Insurance denied payment 7/22. And we received the first bill shortly after that. The anesthesiologist refilled with the insurance company on 8/1 and insurance just denied it again.
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u/CrabConsistent9777 3d ago
But did you call anybody? Just a suggestion, but patient's typically get to see their EOB before the provider, so maybe the provider hasn't seen the second one. They can compare the claim number. There are too many variables that could have gone wrong for anyone here to narrow down. You should get the insurance on the phone and have them call the provider's billing office while you are on the line. Someone from either side could just be reading off their computer screen without actually looking into it any deeper. Let them fight it out in front of you, otherwise you might be in this endless cycle of them pointing a finger at each other.
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u/PresentHat6725 3d ago
Have you sent eob to dr office ?
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u/JulesSherlock 3d ago
No. I figured they received that info from the insurance company. My husband’s insurance called them in order for them to refile so they have actually spoken to each other.
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u/PresentHat6725 3d ago
That doesn’t happen all the time. It could be a glitch in the system. I used to work for a hospital in Pa.
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u/Stock_Run1386 4d ago
Funny that when I take my dog to the vet, it’s very simple and there’s no headaches with co-pays, employer sponsors and other nonsense. I just pay what they bill me. That’s because we pay for it ourselves instead of a third party. Supply and demand. And pet insurance is available if I need it, and the average premium for that is 62 bucks a month. Economics, people. Understand it
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u/Mysterious-Art8838 4d ago
I can’t figure out the point of this.
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u/Stock_Run1386 3d ago
That’s because you can’t figure out basic economics. Why is there no “crisis” of people not being able to afford to take their dogs to the vet? The market handles this fine but we can’t even have the conversation about the market handling medical care for us?
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u/SignificantSmotherer 4d ago
Pet insurance isn’t comparable to people insurance.
You’re typically paying $800-1000/year for up to $5-8K in potential reimbursement. Everything above that is out of pocket.
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u/Resse811 3d ago
Depends on your plan - our plan has no limit on reimbursement. We’ve gotten back $18k this year so far. Obviously this has not been a normal year in terms of cost for us - but we pay $250 a year for a deductible and then get back 90%
I still have no idea why this was mentioned on a health insurance sub as per insurance is far different…
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u/Stock_Run1386 3d ago
It’s different because it’s actual insurance that’s framed to risk as opposed to a compelled third party pre-paid service. The market handles pet care and yet it’s not a headache.
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u/milkpickles9008 4d ago
I've never heard that in 10 years of working in the industry.
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u/bethaliz6894 4d ago
Never heard of that in 30 years of working in the industry and 50+ years as a patient.
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u/Resse811 3d ago
lol what? I’ve had 20+ surgeries and not once has anesthesiology ever not been covered.
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