Insurance Billing Issue- How to dispute when dr's office screws up?

[Anonymous]

Hello,

I have an issue. I have FEHB aetna open access- just switched last January. My dr is not a preferred provider but I have been seeing them for several years. The office is aware of my insurance change and my insurance policy requirments. I recently had my annual pap smear and a follow up colposcopy. The office was supposed to get precertification but failed to do so. Now I am being billed approximately $1,500.00. I have already made an appointment with a new in network doctor as I had planned to switch for other reasons. How do I handle this? Pay the bills (dr and lab) and write a letter to dr's offcie disputing it? File a small claims action? Refuse to pay the bills? I really don't want to risk dealing with billing department calling me all the time. Can I pay it and dispute it at the same time? Any insight is appreciated. TIA

[Anonymous]

What are you being billed for? Just the colopscopy? I would call your insurance company and find out if a claim was ever put in. If no, call the office and speak to the office manager or billing dept and say what happened. Any good office (this has happened to me at 3 different doctors) will put your bill on hold while they attempt to back date the procedure with your insurance.

If you are being billed for the office visit and standard office visit care (pap smear etc) then unfortunately you might be SOL. Most of the time if you go to an out of network provider, it falls on the patient to get it covered. Kind of like if you have an HMO and need a referral.

Either way, call the billing dept and ask for an itemized bill listing what the expenses are for. Follow up with your insurance company to find out why they did not cover the expenses. Then follow up with office manager and billing dept depending on what the issue is.

[Anonymous]

If you really believe that you are not liable for the charges, don't pay the bill, OP. If you pay the bill, you are essentially agreeing that you are liable. You'll then have to explain to a judge why you paid the bill when you did not believe that you were liable.

That said, you might actually be liable. You doctor is not in-network. Thus, his office is not bound by your insurance company's procedures. It might well have been your responsibility to ensure that the colonoscopy was pre-certified. Check the handbook that your insurance company provided during the open enrollment period.

In your position, I would try hard to get the claim paid.

First, ask the doctor's office to call the pre-certification line and attempt to have the procedure "pre-certified" retroactively.

Second, appeal directly to the insurance company. Try to speak with the pre-certification department to find our what the criteria are for pre-certifying your procedure. Then write to them and ask them to review your claim. Explain how you would have met their pre-certification criteria had the doctor's office called. Included copies of your medical records.

Third, write to OPM and them to intercede one your behalf. Explain that you would have met the pre-certification requirements, but your out-of-network doctor forgot to call.