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I'm in the middle of another dispute between an in-network doctor's billing office and my health insurance company (HIC). My health insurance has not yet paid the bill due to a dispute over some diagnosis code used.

Instead of resolving the dispute with my health insurance company, the doctor's biller is sending me a bill for the full amount - prior to any final payment or Explanation of Benefits (EOB) which would show my patient responsibility amount due.

I have not yet received correspondence regarding these claims from the HIC, but I have called both the biller and HIC regarding this dispute attempting to get them to resolve the dispute so I will know my amount due based on final EOB for each claim.

My question is regarding the amount of time allowed for the HIC to dispute this claim with the biller before they are required to either accept or deny the charges formally with an EOB sent to me. Is there a legal time limit for the HIC to process each claim received? I hate being stuck in the middle of billing disputes like this and receiving bills for claims which I do not yet have an official health insurance patient responsibility amount due yet.

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    Unless you can find some legal documentation, it's going to be up to your insurance company.
    – Engineer2021
    Commented Jul 18, 2014 at 15:58
  • Thanks @staticx, I was afraid that might be the case. I guess that's why these disputes can drag on for more than a year. I'll keep good notes and all the documentation until it's resolved. This is the type of thing we need fixed with USA health-care reform. Billers should be required to only deal with insurance companies so patient is not stuck in the middle of a billing dispute.
    – Mister_Tom
    Commented Jul 18, 2014 at 16:03
  • Oh I know, I wish it could be simpler. My daughter just had surgery and there were bills from about a dozen doctors. Hopefully I get one bill instead of 12!
    – Engineer2021
    Commented Jul 18, 2014 at 16:04
  • Good luck, @staticx. I had elective surgery early this year and a bill from yet another part of the team finally reached me last month. (Anesthesiologist, if I'm remembering correctly.) Part of that is probably delays in processing their parts of the claim through my health insurance, but it also seems to just be because, even in a hospital, each doctor and department does their own billing and may not get around to submitting the claim for months.
    – keshlam
    Commented Oct 4, 2014 at 2:26
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    Typically if your office is in network they have an agreement with your insurance company that they will not bill you without billing them first, so that things like your deductible are taken into account. My wife works in the area, its extremely likely that yurt doctors billing department used the wrong codes and they don't match the notes, so the insurance isn't paying until the dr fixes it (and rightfully so). I would talk to your insurance, but I think it would be unlikely you need to pay anything except a copay until this is resolved.
    – Andy
    Commented Jul 18, 2015 at 0:16

2 Answers 2

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It can take a very long time - years in some cases - and as I understand it it's between the service provider and the HIC to come up with a time. Although it is unusual in my experience to get invoiced for the full amount so quickly.

The provider is billing your HIC as a courtesy to you -- technically you're responsible for the full amount. In practice it almost never works that way, of course.

Unless the service provider is threatening to take you to collections it is probably safe to ignore the invoices until you get your EOB. Medical billing systems will fire off invoices automatically.

If you have concerns, you should call both your insurance company and your service provider.

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    problem is, you are responsible for an amount you often can't afford to pay without the insurance, leaving you in a rather tough spot.
    – Andy
    Commented Dec 30, 2014 at 17:49
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    "The provider is billing your HIC as a courtesy to you -- technically you're responsible for the full amount". That's very incorrect. If the dr has a contract with the insurance (and they very likely due, or would not be in network) then the insurance is responsible for paying per terms of your insurance, while you pay copays or deductibles, they pay the rest. If the dr isn't getting the insurance to pay because they are submitting incorrectly, they are probably not allowed to go after the patient. They may not be allowed to bill until after the ins accepts the claim.
    – Andy
    Commented Jul 18, 2015 at 0:25
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    Hi Andy, I'm afraid you're misinformed. Almost all health care providers require patients to agree to a courtesy billing agreement. I'm on mobile so I could only find one example, but here's a hospital's example: whidbeygen.org/my-hospital/financial-services/courtesy-billing
    – Entendu
    Commented Jul 18, 2015 at 4:14
  • This is unfortunate about in-network providers billing directly to patient when insurance fails to pay or resolve billing issue in timely manner. I hope health care reform in USA will add protections for insured patients so this won't be able to happen in the future. Insurance is there to serve the patient, not screw them over through complex erroneous billing process.
    – Mister_Tom
    Commented Jul 18, 2015 at 13:28
  • @Entendu Sorry, but you're full of it. My wife works in this exact area. Any statement such as the one you linked would be null and void due to the pre-existing contract the provider has with insurance. In fact even asking a patient to sign such a form may be a breach of the contract between the provider and insurance company.
    – Andy
    Commented Jul 20, 2015 at 12:49
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Some Insurance companies REQUIRE the healthcare provider to file any claims to a patients insurance. Every contract is a little different. I can't stress this enough, get an Evidence OF Coverage EOC from your insurance and read it.

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