Doctor Did Not Obtain Prior Authorization, Now I’m Being Billed
Last July, I underwent a nuclear medicine test, but I recently discovered that the doctor failed to request prior authorization, resulting in my insurance denying the claim.
For the test itself, which cost about $2500, the provider wrote off the balance. However, for the doctor’s interpretation of the test, I was charged approximately $300. According to the insurance EOB, I should owe nothing, and an insurance representative confirmed they can’t bill me for the balance. Despite this, when I contacted the billing department at the large university hospital, they insisted that they can bill me for the balance and that I am responsible for any amounts not covered by insurance—even though this situation stems from their error.
I’ve seen some comments where others claim, “they can’t do that!” or “our office always absorbs the cost,” but I’m left wondering what happens if they decide not to waive the charges. If they maintain that they can bill me, what are my options? Is there any legal basis that protects me from being billed in this situation, or is this common practice to remain in-network? I’m seeking advice on what steps I can take to resolve this issue.
It sounds like you’re in a frustrating situation, and it’s understandable to seek clarity on your rights and options. Here are some steps you can take to address the billing issue:
Documentation: Gather all relevant documents, including your insurance Explanation of Benefits (EOB), any communications with the insurance company, and bills from the hospital. This documentation will support your case.
Contact Insurance Again: Since the insurance representative stated you owe nothing, ask them for clarification in writing. This can serve as formal proof that you are not responsible for the balance due to the prior authorization issue.
Billing Department Follow-Up: After gathering your documentation and any written confirmation from your insurance, contact the hospital’s billing department again. Explain the situation, reference the EOB, and mention that the insurance company has stated they cannot bill you. Ask them to provide a clear explanation of why they believe you are responsible for the charge.
File a Complaint: If the billing department insists you must pay despite your insurance coverage, you may consider filing a complaint with your state’s insurance commissioner or the appropriate regulatory body. They can investigate and advise you on the situation.
Patient Advocate: Many larger hospitals have patient advocates or ombudsmen specifically for situations like this. They might be able to mediate between you and the billing department to resolve the matter.
Review State Regulations: Research your state’s laws regarding healthcare billing and consumer protection. In some states, there are laws that protect patients from being billed for services that did not have prior authorization when it was required.
Seek Legal Advice: If the situation does not resolve and you continue to be held liable for the charge, consider consulting with a healthcare attorney. They can provide legal guidance based on your specific circumstances and help you understand any applicable laws.
While it can be disheartening dealing with these situations, taking these steps can help ensure that your rights are protected and that you are not wrongfully charged for services rendered without proper authorization.