Subject: Confusion Over Billing and Prior Authorization
I recently discovered that my doctor failed to request prior authorization for a nuclear medicine test I underwent last July, leading to my insurance denying the claim.
For the procedure itself (approximately $2500), the provider wrote off the amount, but I was billed for the doctor’s interpretation, which totals around $300. According to my insurance’s Explanation of Benefits, I owe nothing, and the representative confirmed that they cannot bill me for the balance. However, when I reached out to the billing department at the large university hospital, they insisted that I am responsible for the balance, regardless of the insurance not covering it due to their error.
I’ve seen others mention that providers cannot bill for such situations or that their offices often write off balances. My concern is what happens if they refuse to write off the balance in my case. What are my options if they continue to insist on billing me? Is there any legal basis preventing them from doing so, or is this simply a practice to maintain their network status with insurance providers? I’m curious about my potential recourse in this situation.
It sounds like you’re dealing with a frustrating situation. Here are some steps you can take and information that may help clarify your rights:
Review Your Insurance Policy: Check your insurance policy documents for details on prior authorization requirements and what your financial responsibilities are. This may provide insight into the situation.
Gather Documentation: Keep all records, including the Explanation of Benefits (EOB) from your insurance, any correspondence with the insurance company, and communication with the hospital’s billing department. This documentation will be helpful if you need to escalate the matter.
Contact Your Insurance Provider Again: Since the insurance rep told you that you owe nothing, ask them to provide that information in writing. This can strengthen your case when dealing with the hospital’s billing department.
Speak to a Supervisor: When you contact the hospital’s billing department, ask to speak to a supervisor or a billing advocate. They may be more knowledgeable about these situations and able to help resolve the issue.
Appeal the Bill: If the hospital insists on billing you, consider formally appealing the bill. You can submit a letter explaining the situation, highlighting that the insurance company states you owe nothing, and include supporting documentation.
File a Complaint: If the hospital continues to insist on billing you despite the insurance confirmation, consider filing a complaint with your state’s insurance commission or the hospital’s patient advocacy department.
Seek Legal Advice: If other attempts fail, you might want to consult with a legal expert specializing in healthcare billing issues. They can provide more tailored advice based on your specific situation.
Check for Consumer Protections: Some states have laws that protect consumers from unexpected medical bills, especially in cases of provider errors. Familiarize yourself with these laws to see if they apply to your situation.
While it can be disheartening when a provider does not take responsibility for a prior authorization oversight, standing firm and utilizing the available resources can help you navigate this challenge. Good luck!