Do I have to pay a medical bill when the ER never submitted it for an insurance claim?

Question

My husband went into cardiac failure while we were traveling. He was taken by ambulance to the nearest hospital ER. I gave his insurance information at the time of service.

About a month later, I received a phone call from the billing department requesting more information. I complied, giving them what they asked for along with copies of our Medicare Advantage insurance card.

Months later, the billing office called again for the same information. I told them I have given this to them twice, why are they asking for it again? They apologized and said that someone must have misplaced or lost the information. So I gave it again.

Two years later, I received a bill for $3,625.00 . They said I failed to respond to their attempts to collect the balance due. They asked me to pay it in full no later than 10 days or be sent to collection. I noticed the insurance information on the statement. It also showed that the insurance was never billed and they were billing me for the full amount.

I then called the billing office and asked why our insurance was never billed. She had no answer and said that she would send it back to billing and find out what happened. She told me to call back in three weeks. Here we go again.

It has been a little over two years. Everything in our lives has changed since then and we no longer have this coverage. We are disabled seniors living only on social security. We have very little to live on. The hospital accepted our insurance at the time of service. If the insurance was billed in the beginning, this would have been paid in full. Is the insurance going to pay this charge? Will we have to pay this bill?

Answer 1

Waiting two years is weird. However it's possible that this whole thing got a 15-month "pause" because of the pandemic, and that would make the timing more plausible.

Regardless, do not let this stress you out. It's just a normal and common billing snafu.

Contact your (old) insurance company

The old company will cover the claim because the event was during the time of their coverage.

Generally, insurance companies will mail you reports and statements. They will describe the services you got, the "insurance company rate" the hospital charges for that service, what fraction of that service is picked up by the insurance, and what fraction is your "co-pay" or otherwise your responsibility.

In other words, the insurance company will tell you when and how much to pay the doctor.

It sounds like the hospital botched their billing. It happens all the time - one went in circles because they copied only one side of my insurance card, meaning the only number on it was for the wrong department.

You should submit all the info you have to your insurance company. Most likely they will reach out to the doctor's billing office and either settle the account for you if it's their pay-in-full, or get the bill into their system so that the proper price is charged and so you split the bill properly with the insurer.

The only thing is, you need to stay in front of this and not let it "slip through the cracks" again. It's annoying that keeping your money should have to be work, but that's how life goes with private insurance.

Answer 2

In addition to Harper's answer, if the insurance company also gives you the runaround, here are some reasonable next steps:

• Write down everything. Focus on the facts; don't editorialize or write your opinions, just put down what actually happened. Keep any written documents which can corroborate your story.
• Keep talking to both the hospital and the insurance company. Do not acknowledge the validity of the debt. Do not agree to pay anything. Just keep telling them that they should work it out between them, and it should not be your problem.
• The insurance company may want you to pay for the current year's deductible. This is probably not correct, because the cost was accrued in a previous year, whose deductible you presumably already paid. They may also ask you for coinsurance or other costs; you will need to consult your policy to determine whether this is valid.
• If the hospital doesn't just hand the debt off to the insurance company altogether, they will almost certainly try to haggle with you. In general, the "sticker price" in American healthcare is a made-up number that nobody actually pays (except people who don't know any better). They will bring the price down until they think you are able to pay.
• It's possible that the insurance company will decide (or has already decided, but neglected to inform you) that some portion of the bill was "out of network" or otherwise not covered. Unfortunately, there's not a whole lot you can do about that, if they are correct in their assessment. But they might be wrong about that, so be sure to dig into all of the details and verify that they got it right.
• Consider talking to a lawyer, if it looks like you're going to end up in court.
• Familiarize yourself with the Fair Credit Reporting Act and the Fair Debt Collection Practices Act. If your bill gets sent to collections, you are going to need to know the ins and outs of those laws in order to protect your rights. Here are some of the more pertinent bits:
  • Debt collectors are not supposed to contact your employer, and you can demand that they conduct all business in writing. They are also not supposed to lie to you, intimidate you, or use other coercive or unethical means to get you to pay. Ultimately, you can force them to either file a lawsuit or stop contacting you. If the debt is of dubious validity, many will choose to stop contacting you as the lawsuit is unlikely to be worth it to them. However, they will sometimes turn around and resell the debt to another collector, so you might have to start the whole song and dance over again.
  • You can, and should, monitor all three credit reports (at http://annualcreditreport.com, not at any other site that claims to offer a "free" credit report) and complain if you see any debt which you do not recognize as valid. Whoever provided that information is required to either verify or remove it within 30 days.
  • If the laws are violated, and you can prove it, then you can complain to various people depending on the specifics, but the FTC and the CFPB are probably good starting points in most cases.
• Do not pay any portion of the debt unless you are satisfied that you genuinely owe the whole debt. If you make any payment towards the debt, no matter how small, it may reset the clock on the statute of limitations, and they may also try to use it as evidence that the whole debt is valid. But if you have a written agreement to fully pay off the debt for less than the full amount, then that is probably binding.
  • You can try sending them a check that says "complete and final settlement" on the memo line, made out for the amount that you think you owe. Depending on the circumstances and applicable law (out of scope here), the rest of the debt may or may not be legally extinguished if a creditor cashes that check. Ask a separate question if you really want to try this trick, because the law is rather complicated.
  • Supposedly, some creditors will offer a "pay for removal" deal, where you basically pay them to fix your credit report and go away. The credit reporting agencies do not consider this a legitimate service; if the creditor takes the money and runs, you're probably going to have a hard time getting them to uphold their end of the bargain.
• Once the statute of limitations has run (length varies by state), debt collectors may still try to contact you. Tell them the debt is invalid and refuse to discuss it with them.