Medical Billing Dept. vs Medicare vs Patient

Parents Forum Parent Cafe
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I’d love to hear the wisdom of this group. Anyone in Medical Billing? Confusing, so apologize for length.

Medical billing department (shortened to MBD) submitted a bill to Medicare for my virtual office visit. It was never paid. MBD is now threatening to send to a collection agency. MBD never mailed or emailed an invoice to me. I never received an insurance EOB, but Medicare doesn’t always send EOB’s in a timely manner. This visit was for an acceptable Medicare service.

DH (not me), was informed over 12 months after my visit, that the bill remained unpaid. That was a surprise. Since I never received an EOB, I checked online Medicare. Online Medicare showed about ½ was already paid by Medicare for this visit. I also checked my Supplemental Insurance online, but there was no record of this visit with them at all.

MBD claimed again that they were never paid anything, and because the invoice was over 12 months, said I am required to pay the full amount (including what is shown as having been paid) and instructed me to call Medicare and resolve myself.

I called Medicare. Medicare told me their lack of payment was the fault of an MBD error; that it falls under “provider education”; that I was not responsible for this bill; and that the MBD needs to contact Medicare to discuss. Medicare had approved the services, paid part of the claim, then evidently withdrew it because MBD never answered Medicare’s request for a clarification. (None of this is shown online; it only shows provider was partially paid).

Simultaneously, MBD sent me a threatening letter, complete with deadline, showing I agreed to pay any bills not paid by insurance (which we all sign when seeking medical assistance). This same signed “contract”, however, also states MBD will bill insurance on my behalf, and that MD office will take a copy of my insurance card at each appointment per insurance contractual requirements.

MBD said I did not provide them with a copy of my Medicare card, and that they still had my prior insurance information. (I had no idea this had not been updated. I’ve been on Medicare for over 2 years). And if MBD did not have my current insurance information, it is a mystery (to me) how they even submitted to Medicare rather than my former insurance, with my correct Medicare number, but other erroneous information.

The billing amount is the hundreds (not thousands), but imho – and in Medicare’s opinion – it was a billing or procedure error by the MBD. The MBD says it is my problem, since I agreed to pay unpaid bills. However, had they fulfilled their part, in verifying insurance information, or even contacting me in a timely manner to answer any questions, the bill would have been paid by Medicare!

My responsibility, MBD responsibility, or both? Offer to pay half? Pay all and be done with it? Everyone has warned that once I pay the bill directly to the MBD, I will never see reimbursement from either them or from Medicare. Obviously, I prefer it not go to a collection agency either.

This is for a simple office visit. How does anyone with a severe medical condition, and multiple bills deal with all this?

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Just a thought. Once in collections is it out of their hands?
If it were me, I would try to ask the office MBD to resubmit with correct code and remind of correct numbers for medicare and supplemental insurances.

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I have experience in this on both sides (as a patient and provider). Since you’ve already spoken with Medicare and they said it was a billing error you need to deal with the medical billing office. Politely call and explain that you are not trying to avoid paying bills and you will be happy to make any payments you owe once all of the issues have been ironed out. Make sure they are documenting every call you make and it’s documented that you are not ignoring the situation. Keep all of your own documentation as well of every phone call to either party.
Explain to them that the bill needs to be resubmitted with the correct billing codes. There may be an issue with “timely” billing on their part but I think they can show that it was billed before but this is a corrected billing.
This has usually worked for me.
However, in one instance I was getting no where with the medical provider billing office and we hit an impasse even after the insurance company called them and explained. In that instance, in my last call to them I explained that we had hit an impasse and I would be turning the case over to the insurance companies “balance billing/fraud department “ and that I would then pay the portion I was responsible for.
By that afternoon the billing office called and said it was all straightened out and that I owed nothing (as I had suspected)
No provider wants any issue turned in to the insurance “balance bill/fraud department”. I tried for months before going to that option but it was my insurance company that suggested this approach.
Full disclosure, this was not Medicare.
@kjofkw

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If you care about your credit your best bet is to suck it up and pay it and if you can, send a nice “personal and confidential” hand written greeting card to the care provider (marked as such so hopefully it actually gets to the doctor) and let the provider know that because of his office’s billing business practices you will take your future business elsewhere and explain the saga. It probably wont help, but the doctor should know what his billing office is doing to the patients he or she purports to care for.

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@rockymtnhigh2 : MBD is insisting it is no longer their problem. To my knowledge, they haven’t submitted to collections (yet). Just threatening so far. They say they won’t (or can’t) resubmit because it has been over a year. They submitted w/ correct medical code. Medicare actually approved – then withdrew because they wanted a minor clarification. It appears from records, MBD chose to close claim, rather than pursue further – all well within 6 months of the 12 month deadline, but with no outreach to me until after the deadline. It would have been an EASY fix had I simply received a call or email. But MBD chose otherwise.

MD office won’t let me contact billing office (a separate entity). They are currently acting as intermediary, but at the same time simply saying "they told me to tell you…). Very frustrating. I assume purposefully, there is no contact information (phone, email or otherwise) for the billing department. I have no idea how they are relaying my information to them, so I’ve started emailing the MD office.

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If you have any idea what your portion of the bill will actually be then I would pay that amount only, to show good faith.
There is something wrong if they won’t let you talk to the billing office!!
Providers know the health issues but they rarely fully understand coding and billing issues. That is the job of the billing office. I
I would talk to your insurer and ask about their “balance billing/ fraudulent billing” department.

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Thanks @bhs1928 for your insight! All extremely helpful.

I met my deductible. My portion of the final bill SHOULD be $0. Often, what is billed by the MD’s office does not match what has been negotiated with Medicare (or other Insurance companies). I don’t know definitively without an EOB.

But, for this particular visit, Medicare would have paid their part and my Supplemental insurance should have covered the rest. It never got sent from Medicare to my Supplemental though, because MBD closed the claim without responding to Medicare’s request for corrected information.

I’m actually starting to wonder if all this is just multiple mistakes made along the way, or if truly it should go to the “balance billing / fraudulent billing” hopper.

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Multiple mistakes along the way can lead to balance billing or fraudulent billing. If Medicare asked for clarifying information and MBD did not follow through then that turns into balance billing (or fraudulent billing if they knowingly closed the case without providing the information).
Balance billing is trying to get money from the patient over and above the negotiated contract. The MBD is not allowed to balance bill you or close your case until all issues have been resolved. If Medicare says “Patient responsibility” is zero then that is part of the negotiated contract. If MBD had provided the clarifying information then Medicare would pay their portion and let you and them know your responsible portion and then that responsible portion goes on to your supplemental insurance.
Multiple mistakes along the way does not relieve the billing department from fraudulent billing.
If Medicare says $0 at this time then any amount they try to come to you for is balance billing and balance billing is illegal.

Insurance companies can also deny coverage for not billing in a timely manner but that is the responsibility of MBD and not the patient.

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If i remember right, Medicare has a timely filing limit of 12 months and won’t pay beyond that. I’m wondering even if the MBO corrects it now if they’ll even accept it.

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It’s really not the patient’s problem if the billing department messes up such that a proper claim isn’t made during the correct payment window. That’s on the BD. I’m sorry for the hassles and threats of collection. So uncalled for and unfair.

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This article shows some of the problems between medical billing and the patient. I thought it was interesting to this situation

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If you value your credit, it’s wise to pay the bill. Consider sending a handwritten “personal and confidential” card to the care provider, expressing your concerns about billing practices. Mention your decision to seek care elsewhere due to these issues. While it might not have a direct impact, it informs the doctor about their billing office’s effect on patient experience.

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2 comments:

  1. File complain with office of Attorney general for Health Insurances of your state explaining everything.
  2. Under new law if your health insurance bill was under $500 , it will not ruin your credit history however it may not stop collecting agency…
    If 1 is done I suspect it will not end up in collection but I am not an expert…
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OP here. Since there were new posts, here is a summary of our billing issue noted above. Much more complicated, and more steps IRL, but some interesting outcomes.

PCP continued to stress that I pay the full amount (more than negotiated insurance amount), and that I solve the issue with Medicare directly. I called Medicare each time PCP pushed for payment.

Each Medicare call required a repeated explanation with a new representative, who had slightly different advice, but each time they confirmed that my responsibility for the office visit was $0, and finally sent a MSN (EOB) with that noted. I never received one earlier because they actually paid the PCP (twice) and rescinded payment when PCP failed to supply some requested information. One representative said the MBD could now bill me only 20% of the original Medicare negotiated amount.

Trying to better understand my financial responsibilities, I called the state Medicare ombudsmen office. They were extremely helpful during discussions, and advised I pay the 20%, mark the check “paid in full” and send via registered mail. So I did.

Interestingly, Medicare reps shared ( several times) that the PCP was issued multiple “assignment violations” on this matter. I asked for a written confirmation of that as well, but never received one.

PCP cashed my check, crossed out my notation, wrote both DH and I that they would no longer be our PCP, and sent the balance to collections. I mailed collections a summary of events, and phone discussions with Medicare with a copy of the MSN. Never heard from them again. No credit ding.

I was advised to submit a complaint to the state attorney general, or the state insurance department. However, without anything in writing to support my phone conversations with Medicare or OSHIP, I decided best to move on. Sadly, I noted later on online reviews of this MD office, that several others also had issues with their billing practices.

Was it worth the aggravation and multiple calls? Definitely not worth my time for one office visit, but DH & I always felt this MD billing office previously stretched the limits of what was acceptable billing and frankly, we had enough. I can be very stubborn :wink: Multiple “small” mistakes with multiple patients often add up to a pattern!

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That sounds like a blessing in disguise. You didn’t really want to see them again anyway…right?

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Was this a solo or small office practice?

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@ucbalumnus : VERY small office with in-house office manager who coordinated billing. @thumper1 : There was no question we were going to leave anyway. Sadly, the medical staff was fine. It was the office manager and billing practices that were an issue.

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Makes you go hmmmm that there was something going on.

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Go from there. MBD can figure it out.

By ignoring most of the thousand bills you get that don’t really need to be paid. After a while it’s almost an art.

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I haven’t read the whole thread, but you may want to check whether your former PCP’s office accepts Medicare assignment. They are free not to but they should have told you or you should have asked them. If they take assignment, then you are under no obligations to pay them more than what Medicare says the visits should cost. If you don’t have Medicare supplement, then you should pay the balance, any deductibles and 20%.