What is the law regarding my physician billing my health insurance provider versus billing me?

UPDATED: Jan 7, 2011

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What is the law regarding my physician billing my health insurance provider versus billing me?

My physician’s billing department won’t appeal a denied claim from my health insurer because they said that they only billed them as a courtesy to me. My health insurer is asking for an EOB and an acceptance report and the physicians group said they don’t need to provide them with anything. They said I am liable for full amount and are sending me to collections tomorrow. It was an ER surgery with a non-network provider.

Asked on January 7, 2011 under Bankruptcy Law, California


M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 12 years ago | Contributor

You need to fight this and let's start with the basics.  You were taken to the ER.  You have coverage for an emergency situation and for the hospital you were taken (not that you have a choice in an ambulance sometimes).  Emergency surgery was done.  If you were covered for the ER visit and it was an emergency surgery then you should indeed be covered.  You generally do not have an obligation in that type of situation to start requesting information as to whether or not the doctor doing the procedure takes your insurance.  Your insurer has every right to request and EOB but if it was an emergency situation they can not deny coverage.  Tell the Doctor's office that you are reporting them to the state licensing department and to the State Insurance Department.  Then call your insurance company and tell them the same.  Then do it.  Call the State Department of Insurance anf file claims.  And when you talk to the MD and your insurance keep asking for supervisors and take names.  Good luck.

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