Navigating Insurance Billing: What To Do When Your Doctor's Office Refuses To Bill Your Insurer

If your doctor's office refuses to bill your insurance, there are several steps you can take to resolve the issue. Firstly, it is important to determine whether your doctor is in-network or out-of-network with your insurance plan. If they are in-network, they are usually contractually obligated to bill your insurance directly. In this case, you can request that they bill your insurance company, and provide them with your insurance information if necessary. If they are out-of-network, they may not be required to bill your insurance, and you may need to submit a claim to your insurance company yourself.

If your doctor's office is unwilling or unable to bill your insurance, you can try contacting your insurance company directly. Explain the situation and ask if they can help resolve the issue. You may also need to submit an appeal or dispute if your insurance company denies coverage for the services you received. It is important to keep detailed records of all communications and bills related to the issue, as this information may be needed for appeals or disputes.

If you are unable to resolve the issue with your doctor's office or insurance company, you may need to seek assistance from a medical billing advocate or a patient advocacy organisation. These organisations can help you navigate the complex world of medical billing and insurance and may be able to help you resolve the issue. Remember to act promptly, as many insurance companies and medical providers have time limits for filing claims and appeals.

Ask your doctor to submit a claim to Medicare

If your doctor refuses to bill Medicare and does not specify why, you can report this as it is often considered Medicare fraud. You can do this by contacting 1-800-MEDICARE, the Senior Medicare Patrol (SMP) Resource Center (877-808-2468), or the Inspector General’s fraud hotline at 800-HHS-TIPS.

If your doctor still refuses to bill Medicare, you can try filing the claim yourself. You will need to submit a Patient's Request for Medicare Payment form (also called the CMS-1490S form) to the Medicare Administrative Contractor (MAC) in your area. Send bills or receipts for the service along with the form. After processing your request, Medicare should either send reimbursement or a coverage denial that you can appeal. To find the MAC in your area, call 1-800-MEDICARE.

If you have Original Medicare, the law requires doctors and suppliers to file Medicare claims for covered services and supplies you get. If you have a Medicare Advantage Plan (Part C), these plans don't have to file claims because Medicare pays these private insurance companies a set amount each month.

You have 1 year to file your Medicare claim after receiving services covered by Medicare.

Contact your insurance company

If your doctor's office refuses to bill your insurance company, you should contact your insurance company to explain the situation and ask for an appeal. Sometimes, the insurance company will agree to negotiate with your doctor. However, if the issue is that the doctor does not want to accept funds from an insurance company, you will have no choice but to pay in cash or find a different doctor.

• Review your insurance plan: Understand your coverage, including what is and isn't covered, as well as your requirements and responsibilities. This will help you identify any discrepancies or errors in the billing process.
• Gather relevant documentation: Collect all the necessary documents, such as your insurance policy, itemized medical bills, and any correspondence with the doctor's office. This information will be crucial when discussing the issue with your insurance company.
• File an appeal: If you believe your insurance company should be covering the bill or reimbursing you, file an appeal as soon as possible, usually within 30 to 60 days. Include supporting documentation, such as medical records and letters from your doctor explaining their disagreement with the insurer's decision.
• Stay organized and keep records: Keep detailed records of your conversations with the insurance company, including the names of the people you speak to, dates, and summaries of your discussions. This information may be important if you need to file complaints or take further action.
• Expect delays and follow up: Be prepared for possible delays in the process and follow up with the insurance company if you don't receive a timely response. It's important to stay persistent but polite in your communications.
• Seek assistance if needed: If you feel overwhelmed or unsure about the process, consider seeking help from a medical billing advocate or a patient advocacy group. They can provide guidance and support throughout the process.

Request an itemised bill

Requesting an itemised bill is a crucial step in challenging a medical bill. Here are some steps to take:

Step 1: Ask for an itemised bill

You have the right to receive an itemised copy of your bill. This should clearly list every charge so that you can see what you are paying for. Hospitals are legally obligated to provide you with one if you ask for it. Contact the doctor's office or the hospital's billing department to request one.

Step 2: Review the itemised bill

Go through the itemised bill line by line, looking for errors or discrepancies. Check for double charges, coding mistakes, and incorrect calculations. Compare the charges against your health insurance plan to determine what you are responsible for versus what your insurance company covers. Also, check if there are any charges that should be covered by your provider.

Step 3: Contact your medical provider

If you spot any mistakes or have concerns, call your medical provider and explain the issue. Ask them to review and correct any errors. If they claim that your insurance should cover certain expenses, ask for a letter explaining why they disagree with your insurer's decision. Keep a record of the names of people you speak to, the dates, and a summary of the conversation.

Step 4: Contact your insurance company

Review your insurance plan and talk to your insurance company. If you believe they should be covering certain expenses, file an appeal and provide any necessary documentation, such as medical records and letters from your doctor supporting your case. Keep detailed records of your conversations and expect delays in the process.

Step 5: Negotiate with the medical provider

If the issue is still not resolved and you are left with the bill, you can try negotiating with the medical provider. Ask for a discount or financial assistance, and be prepared to provide proof of income or other relevant documents.

Remember to stay organised, keep records of all communications, and be persistent but polite throughout the process.

Appeal to your insurance company

If your doctor's office won't bill your insurance company, you may have to pay the bill yourself and then appeal to your insurance company for reimbursement. Here is a step-by-step guide on how to appeal to your insurance company:

Step 1: Review your policy and paperwork

Before you begin the appeals process, it is important to understand your insurance policy and the reason for the denial. Review the summary of benefits in your insurance documents and look for any limitations or exclusions that may apply. Read over the letter or form your insurance plan sent you when it denied your claim, as this should outline the reason for the denial and the steps you can take to appeal the decision.

Step 2: Know who to call for answers

If you don't understand why your claim was denied or have other questions, call your insurance company and ask for clarification. If the issue is due to a billing error or missing information, your insurance representative may be able to help resolve the issue. You should also call your doctor's office to ensure that they have submitted the correct information to the insurer and to request that they send any necessary paperwork or additional information to support your claim.

Step 3: Learn about the appeal process

Familiarize yourself with the appeal process by checking your plan's website or calling customer service. Ask about any deadlines for filing an appeal and make sure to follow your plan's specific instructions and requirements. Let your doctor or hospital know that you are appealing the decision and request that they do not send you any bills or turn your account over to a collection agency until the appeal process is complete.

Step 4: File your complaint

If your claim was denied for treatment you have already received or will need in the future, ask your doctor's office to send a letter to your insurance company explaining why the treatment is medically necessary. Be sure to include any relevant medical records, letters, and supporting documentation with your appeal. You can also request an expedited appeal if your situation is urgent or if a delay would put your health at risk.

Step 5: Keep a problem from happening again

To avoid having a claim denied in the future, make sure you understand what is covered by your plan and any limitations or requirements, such as pre-authorization for certain types of care. It is also important to verify that your provider is in your plan's network, as some insurers may not pay for out-of-network providers.

Negotiate with your medical provider

Negotiating with your medical provider can be a good option if you are facing issues with your doctor's office not billing your insurance. Here are some steps you can take:

• Get an itemized copy of your bill: Ask your doctor or hospital for an itemized bill that lists each charge clearly. Go through the bill line by line to identify any double charges, coding mistakes, or incorrect calculations. Compare these charges with your health insurance plan to determine what you are responsible for and what your insurance company should cover.
• Talk to your medical provider: Contact your medical provider and explain why you believe there has been a mistake. Ask them to review and correct any errors in the charges. If they claim that your insurance company should cover certain expenses, request a letter explaining their reasoning. Keep records of the names of people you speak to, the dates of conversations, and summaries of what was discussed.
• Negotiate a discount: If you are still responsible for a portion of the bill, you can try negotiating with your medical provider. Ask for a discount and provide proof of income, large expenses, or disabilities that affect your ability to work. Some providers may be willing to offer discounts of up to 20%.
• Discuss financial assistance: If you are unable to pay the bill, talk to your doctor or hospital about financial assistance programs. You may qualify for partial coverage or alternative payment arrangements.
• Understand out-of-network providers: If your doctor is out-of-network with your insurance, they may not be required to bill your insurance company. In this case, you may need to pay out-of-pocket and then file a claim for reimbursement with your insurance company.
• Request an Advance Beneficiary Notice (ABN): If your provider believes that Medicare will deny coverage, they must provide you with an ABN. Before signing, ask if they consider the service medically necessary and if they will help you with the appeals process. You can still request them to file a claim with Medicare, as you may be able to appeal a denial of coverage.

Frequently asked questions