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I visited a doctor in August of 2015 that was in-network. They required me to pay for the services up front (in cash, btw). I should have known that was the first red flag, but I needed a prescription refill fast.

It's now January of the following year and my insurance and I have yet to receive a claim from the doctor's office. I tried submitting the claim myself to my insurance for reimbursement (I have a HRA through my place of work that reimburses me for 100% of my in-network services), but they cannot reimburse me without pertinent info from the doc (such as diagnosis codes, tax ID number of the doctor, an itemized receipt, etc.) I should not have had to pay upfront per the doctor's contract with Cigna, but they forced me to. Again, I shouldn't have paid, but I figured I would be reimbursed down the line.

I've tried calling and emailing both the doctor's office and my insurance 20+ times combined over the past 5 months to resolve this. Each time, the doctor's office says "We cannot control when our billing department submits the claims". When I pressured them, they lied and said "Oh our billing department sent that out last month". They also hang up on both myself and my insurance company when we call them.

My insurance company seems to only provide assistance in the form of calling the doctor's themselves and asking them to submit the claim per their contract (90 days in NY, I believe. It's been 5 months...)

I'm wondering the following

  • What more can I be doing?
  • Is this legal? I'm aware that doctors don't have to submit claims for patients, which is why I did it myself months ago. However, I can't be reimbursed until I have the other information from my doctor. Which they won't give me or send over.
  • What websites, organizations & outlets can I report this to? I don't want any other poor soul to have to deal with this doctor and their negligence. I've already filed a formal complaint with my insurance company as well as ZocDoc (which is where I found this original doctor from), but nothing seems to really impact this doctor's office and make them change their ways.

Any other tips/horror stories would be helpful as well. Thanks!

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    small claims court might be a valid option -- I bet they submit the claim very quickly after being served with a lawsuit. it's not expensive to file and will get their attention.
    – Rocky
    Commented Jan 20, 2016 at 22:18
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    I had the same experience. Once they have their money, they couldn't care less about filling forms and filing stuff. They just sit tight and hope you go away and leave them alone. - i agree you can make them move probably by threathening a claim. Going there in person and discussing might help too, if you do it multiple times (and the waiting room gets a whiff of it each time...)
    – Aganju
    Commented Jan 21, 2016 at 2:24
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    I suggest lawsuit (even in small-claims) and the State regulator (check for the agency that regulates doctors, or a consumer protection agency in your State).
    – littleadv
    Commented Jan 21, 2016 at 2:58
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    @Brick - Never had an issue with the insurance, but have had MANY issues with the doctor. Doctor has been saying since August "we told our billing department to send it", with no action happening. This particular doctor also has numerous other complaints (all of a similar matter to mine) on their online reviews.
    – Rachel Ferrigno
    Commented Jan 22, 2016 at 14:05
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    @Brick, a network contracted provider requiring a full cash payment for a covered benefit is a red flag that the provider is engaged in some monkey business. To add to that, now they can't provide the patient with a copy of the submitted claim or the diagnostic codes, tax ID and other pertinent information so the patient can manually file the claim?
    – quid
    Commented Feb 24, 2016 at 18:33

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I'm a business law student, so medical stuff isn't really my specialty. I'll share with you what I know though.

First, as to the legality, I'm not aware of anything making it illegal for them to consider their business with you concluded. Absent any contract between you and the doctor, it seems to me that you agreed to pay them in cash. If I was the business, I'd assume our business had been concluded as well. As for any contracts between the insurance company and the doctor's office, as far as I know, that's between them. That wouldn't give you standing to sue the doctor.

I'm unfamiliar with a patient submitting insurance claims, but if that's something you are allowed to do with your insurance company and all you need is more information, submit a request for your medical records to the doctor. Under United States law, your medical records are yours. You have a right to receive a copy of them. Keep in mind though that the doctor's office may charge you a small copying fee to cover expenses they incur while making a copy for you.

As far as complaining, I would suggest your local Better Business Bureau. Each state generally has a medical board which oversees doctors. You might lodge a complaint with them as well.

I hope this helps. Keep in mind that I'm not an attorney. This is not legal advice. This is only what I personally would do if I were in your situation. You can and should consult an attorney who is licensed to practice law in your particular jurisdiction.

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