If you have health insurance, you expect your medical provider to submit a claim to your insurance company in a timely fashion. After all, the provider asks for your insurance card when you become a patient and likely asks you nearly every visit if your insurance has changed.

But in some cases, a medical provider may not submit a claim to insurance. Or, the provider may submit the claim after the insurance policy’s deadline, resulting in a denial.

Why would a provider fail to submit a claim to insurance? It could be due to an oversight, mistake, or even an intentional omission. In a chaotic emergency room environment, an administrator may be given the proper insurance information but may lose it in the hustle and bustle. Whatever the reason, there can be dire consequences for the patient. Health insurance policies have deadlines for when claims must be submitted. These usually range from 90 days to 1 year. Even if it’s not the patient’s fault, these deadlines can and often will be enforced.  

What happens if a provider or debt collector pursues you for a medical debt that arose because a claim was not timely submitted to insurance?

You can’t stick your head in the sand. You’ll have to address it.

If you’ve received a late bill, you can dispute it with your medical provider. The agreement between the provider and insurance company may require the doctor to file a claim in a timely manner using the correct billing codes. A provider that fails to do this may be barred from billing the patient. You should try to obtain the agreement from your insurance company or enlist your insurance company for its help. 

If you’ve been sued, you need to file a written response to the lawsuit by the deadline. If you don’t, the party suing you will obtain a default, which can turn into a default judgment. Then, the creditor can begin to garnish your wages or bank accounts. So, make sure you respond to the Complaint and if you need extra time to do so, file a request for an extension of time. In the action, you’ll need to deny that you owe the amount billed. You may have a counterclaim for a consumer violation for being billed for an amount you don’t owe.

Whether or not you’ve been sued, you should still file a claim with your health insurer, even if the claim is late. There’s still a chance that you could receive coverage.

Bottom line: you should do your best to make sure the claim is timely submitted to your insurance. We can’t always rely upon hospitals or providers to do this. If you do not receive an Explanation of Benefits (EOB) within 60 days of receiving medical treatment, you should follow up. Check in with your insurer and the hospital or provider’s billing or customer service department.

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Manta Law 2024. All Rights Reserved.

Manta Law 2024. All Rights Reserved.