What is the duty of a medical office to properly bill one's insurance? (USA)

Question

In the US, it is typical for patients to sign contracts with a medical office assigning whatever benefits are applicable from their health insurance to the doctor's office and leaving the patient financially responsible for what is left unpaid.

Is there a minimum standard for doctor's offices to actually complete the insurance process before passing on the rest of the bill, and if so, what kind of remedy is available if they don't?

Example: A doctor's office sends to the insurance company details of a procedure to be paid, but left off one fact that the insurance company needed to complete the claim. The insurance company informs the doctor's office that in order to finish the claim, they have to complete the missing bit of paperwork. Instead of doing so, the doctor's office leaves benefits the client is entitled to unclaimed and proceeds to bill the patient for the unpaid amount.

Is this a valid bill under that standard kind of contract? Is there some kind of minimum due diligence required on the doctor's part, and if so, is there some area of tort law that is available for redress?

Answer 1

To my knowledge there is no actual law requiring a provider to file anything on your behalf. Most do it as a courtesy but if you read the terms of service that you almost certainly agreed to, it will say that YOU are the responsible party.

If the insurance company doesn't pay, even if the provider doesn't submit a claim, the responsibility is still yours. There is nothing stopping you from filing your own claim using whatever forms or procedures that they have established.

I'll also note that many provider networks have rules that providers must adhere to in order to remain in that network. Some may include language about timely filing of claims but that is in no way universal.

These days many providers have taken to billing the patient the full amount immediately and then will issue a refund to you if/when the insurance pays.

Answer 2

In terms of your contract with the doctor, there is probably no contractual obligation for the doctor to submit anything to the insurance company. You can read your contract (if you ask for it, though the written contract is usually fairly minimal, and don't generally constitute a full-blown contract (example). The statement that "Some insurance companies will allow us ... some insurance companies will not allow this" brings in the other party to the process – the insurance company. Some doctors have a particular kind of contract with the specific insurance company, and some do not. So an interesting question is, what does Aetna contractually require of its in-network providers? If the doctor has no relation at all to the insurance company and submits claims as a convenience for their patient, then it's strictly a business consideration how far they are willing to go to save the patient money. But the doctor may have a contractual obligation with the insurer to put in a little extra effort, for the privilege of being an in-network provider. Ultimately, the doctor can simply refuse to deal with insurance companies. There is also Medicare: this might start you on the path to seeing what obligations the doctor has to patients, as a "Part B" provider.

Answer 3

This is the difference with 'in-network’

An 'in-network’ doctor has signed contracts with the insurance network - so they agree not only to bill on behalf of the client, but also settle for insurance pricing. Which is often dramatically lower than retail pricing for the same service. They do this in exchange for the great number of patient referrals they will get, being part of the network.

An out-of-network doctor has no such contractual agreement, is not obliged to bill your insurance (but probably will make some effort out of an interest to actually get paid), and does not need to accept the insurance contracted rate, and can bill you as they see fit.

Some insurers (particularly ACA/Obamacare backed state-actor insurers) prohibit their members from paying doctors privately and seeking reimbursement. Partly, they don't want to deal with the paperwork and fraud risks, and partly, these programs are intended for people who don't have the means to private-pay for medical care.