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So, I've been researching for a quite a bit and haven't been able to find a case or ruling that relates close to my situation.

I went to a sleep specialty physician about four years ago who was covered under my insurance. I provided my insurance information, including billing numbers over the phone a month prior to the visit. The office never contacted me to make me aware that the doctor's office visit would not be covered. I arrived at the appointment, went to pay my copay upfront, and the front office representative told me there was no copay. Upon exit, the office made my next appointment, I asked again if there was a copay, they told me no. I made my next appointment, and once again was met with the same procedure. No copay taken, no information on what the insurance would pay for, kept being met with the same response by the front office when I went to pay.

Before my third appointment, I got a bill directly from the doctors office saying I owed $250.00 for the first visit because my insurance had not met the deductible. I obviously was confused because, times where a procedure was not covered and or a deductible was not met, the office made me aware of the price. So I called the office and asked about the bill, and they tell me they are not liable for not telling me if an insurance doesn't pay for an office visit and I will actually be getting another bill soon for $180 for the second visit. I, of course, tell the office that I will not be paying them due to their lack of disclosure and I will be cancelling my upcoming appointment. I then made the insurance aware of the incident, I never received an "explanation of benefits" from the insurance and I told the practice I was not going to pay due to their lack of competency. I told the office I would pay a reasonable copay, they refused. Years pass and now this month I get a notice of a civil pursuit from a legal office representing the physician asking for $600 in medical and legal fees. The legal office representing the case has been quite unhelpful so far, because they perceived me as not responding to their case back in June as "avoiding" penalty, but I had literally moved to a different state. I made them aware when a representative called me in June, when they tried to serve me papers, which took them two months to send me the documents to my new address.

Of course, this would be a different situation if this was an emergent issue within a hospital where a procedure or service was required without insurance verification and billing is done post visit. But these were regular doctor's office visits where no procedure other then a consultation was provided. Do I have any legal recourse to defend myself from these surprise claims from 4 years ago?

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    This question is more of a legal question and off topic for this site. You might want to try law.stackexchange.com. Based on your description it doesn't sound like you have a leg to stand on. You have a legit reason to complain, but that's about it. Nothing you have said would likely excuse you from owing the money. Whether the insurance paid the bill is between you and the insurer, not them. Your beef should be with the insurance company. – JohnFx Oct 10 at 18:22
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    Not covered and covered but deductible not met yet are two different things. In fact they are often contradictory, because an uncovered service does not count toward deductible (with most insurance at least). And deductible and copay are also different things. So if the office said “yes, this is covered with no copay” and gave you/ your insurance company the negotiated rate, then they did their part. If the insurance company then said, yes it is covered but we pay after the deductible is met, well that is how most insurance works. – Damila Oct 10 at 19:28
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In general in the United States a medical office has no idea if you or your family has meet the annual deductible. Even if they checked on the day you made the appointment, it could change 10 minutes later if you saw another doctor, or filled a prescription.

It can even be made more complex if you are visiting a specialist, or if the provider is out of network.

When you have a policy with a deductible that transition time is complex because the first appointment can be before the deductible is met, the next appointment can be partially deductible, and the 3rd can be after the deductible is met.

It is your responsibility to track these bills so that you can pay what you owe to the doctor after the EOB is generated. You also need to understand what you would be billed if it wasn't covered, and how it works with the deductible. Some offices can work with you to get an estimate through the insurance company, but they generally caution that they can't see your deductible status.

There are some insurance companies that are tightly connected to their providers, I believe one is Kaiser Permanente, but then they limit the providers you can pick from. But they can also know your insurance status and can provide accurate estimates.

In general you can argue with the insurance company regarding who should pay. But the medical provider if they are in-network should be paid if they are following the network rules. If they are out of network many will require you to pay at the time of the visit, and expect you to get reimbursed by your insurance company.

Based on your description you should have been talking to the insurance company regarding the amount you had to pay.

You will probably find that the $600 will be way below what a lawyer will charge to fight this, if you can convince one to take the case.

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When you go in for medical treatment, part of all the forms you sign, there something called a Billing Consent Form. It may even be part of the (Health) Insurance Billing Consent Form. It gives the medical provider the right to bill your insurance on your behalf. Most importantly, it essentially states that you will ultimately be responsible for any and all charges incurred.

The office may or may not charge you a co-pay when at the time of service, that's entirely up to them. Going through the process of billing your insurance is merely a convenience to you as opposed to billing you up front and having you submit the bill for reimbursement. Whether or not you've met your deductible is between you and your insurance company - the medical practitioners office will have no visibility into this.

Ultimately, it is your responsibility to check with your insurance provider, not the doctor, to see if

  • The doctor is within network
  • The procedure/medicines are covered
  • What your deductible is
  • What your copay is

It is frustrating and it sounds antithetical to good customer/patient relations, but they are entitled to get paid for their services. That you were denied coverage isn't their fault.

So, if you did sign this form, you are responsible for the charges - you can ask to see it. However, it is unlikely you will prevail in any sort of legal challenge to this regardless if you signed or not (it just makes their job and their collections attorneys' job easier if you did). You asked for and received services therefore they are entitled to compensation despite being relayed incorrect information regarding your insurance coverage. "Honest" mistakes are not a justification for not paying.

Nothing I say here should be taken as legal advice, it's merely my opinion based on several decades of experience in both medicine and the legal industries. I am not a lawyer and more importantly, I am not your lawyer.

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