I have insurance goddamn it!
September 20, 2012 10:20 AM   Subscribe

My doctor's office billed me up front for an IUD and told me I would be reimbursed. Today, after calling them repeatedly, I found out that they have not filed a claim for the device, and they couldn't give me a satisfactory explanation as to why. I have no idea what to do now.

On September 4th, I had an IUD placed at this clinic (in New York City where I live). They told me at that time that I would be required to pay $650 up front for the device, and would then be reimbursed by my insurance. They said this was because they bought the devices in bulk and kept them at the office, rather than ordering them individually for patients. I thought this was strange- especially because no mention was made of this on my previous screening visit- but I went ahead and put it on my credit card, assuming I would have my money within a month.

It is now September 20th, they have not filed a claim, and they cannot explain to me why they have not done so. Originally they told me they'd filed it, the insurance company must just not have gotten it yet. I found out today that the insurance company HAD received a claim for the visit, but not the device itself. I called today to ask why, and they said, oh, well, WE'RE not the ones who file a claim for the device! It's the device provider, CVS! Call them and ask why THEY haven't filed a claim yet.

I called them- they have never heard of me, do not have a file for me in their system, and they didn't understand the situation I was describing at all.

I called back and told the clinic this. The clinic told me that 'their supervisor will get back to me'.

What the hell is going on here, and what can I do about it? At this point I would be happy to file a claim myself but I mentioned this and they basically brushed it off. I am scared that they scammed me somehow and I will never be able to file a claim for this, and am out $650 despite being fully insured.

What can I do now, besides just keep calling them every day (as I have done for the past 4 days)? Is there some sort of medical advocacy group I can call? I don't have money for a lawyer!
posted by showbiz_liz to Law & Government (21 answers total) 2 users marked this as a favorite
This sucks. Can you put it on a credit card and file with the insurer yourself? At the end of the day, sucky as it is, it's your responsibility to make sure the provider gets paid and then sort it out on your end.
posted by chesty_a_arthur at 10:23 AM on September 20, 2012

Do you have an itemized statement or invoice or receipt given to you at the time of service? That lists the $650 charge for the IUD?

Most insurance companies have reimbursement claim forms that you can fill out and include receipts. Have you called your insurance company and asked about reimbursement procedures?
posted by rabbitrabbit at 10:25 AM on September 20, 2012 [3 favorites]

Sounds shady to me. In addition to submitting a claim with CVS, call NYS consumer protection.

Also, find yourself another gyno. I have never heard of a reputable doctor's office doing such a thing.
posted by Currer Belfry at 10:32 AM on September 20, 2012 [2 favorites]

Response by poster: I believe I have the receipt still- I confess I am not sure where, but it should be in my apartment. What happens if I cannot find it? I do have the record of the charge on my credit card.

What happens if I file a claim, and then the clinic also files one?
posted by showbiz_liz at 10:33 AM on September 20, 2012

When I had my first IUD inserted, I needed to do the claim myself.
posted by roomthreeseventeen at 10:37 AM on September 20, 2012

Best answer: Call your insurance company and speak with a live person. Tell them this exact scenario.

Find that receipt! If you can't find the receipt, look at your credit card statement. If it's not itemized, call your doctor's office billing department - they should be able to provide you with a copy, duplicate or statement of purchase.

You can then submit all this on the back end to your insurance company. They should be able to take care of the rest.

Double-billing is none of your concern - it's your doctor's office's issue to deal with.

Once all is said and done and you receive your payment (which might not be for another month or two because these things take forever) I'd seriously consider reporting your doctor's office to the BBB.
posted by floweredfish at 10:39 AM on September 20, 2012 [4 favorites]

Best answer: If you can't find the receipt, ask your clinic for a superbill, they should know what it is. You can submit that and make sure that your insurance company knows to pay you, and not the clinic for the reimbursement.
posted by quince at 10:42 AM on September 20, 2012

Definitely find the receipt and submit the claim yourself! Do you have a web login for your account with your insurer? There should be forms for claims available on their website. If you can't find the receipt, go in person to the doctor's office and don't leave until they give you an itemized receipt for services rendered.

Also, I am pretty sure that if your doctor's office attempts to file a claim for this service, since you have already paid them in full, they will be committing insurance fraud.
posted by elizardbits at 10:44 AM on September 20, 2012

Best answer: The office has no incentive to file a claim as they have already been paid. Call your insurer again and specifically outline the scenario you have described here. Have them walk you through the process of filing a claim, including what will happen of both you and the office file. Also get the name & contact information of whatever department at the insurer that handle la complaints about their network providers.

Then, write a polite, strongly worded letter to your health care provider stating what you have done and cc the insurer's provider complaint department.
posted by theBigRedKittyPurrs at 10:45 AM on September 20, 2012

It may be because they lose money on IUD's. Your insurance may have a stipulation that the doctor's office order the device specifically for you in order to cover it. If they are giving you the runaround, yes, call your insurance company. And read this thread about a similar issue.
posted by Marie Mon Dieu at 10:52 AM on September 20, 2012

It's a long shot and I am not at all versed in the intricacies of how this stuff works or the legality of it in the US, but can you do a charge back on your credit card to get the money back, they might be motivated to file with your insurance then. You paid for a particular service which included filing a claim for the money back through insurance, they didn't provide the service.

Though filing the claim yourself might be easier in the long run, I'd look into that too as there might be a time limit on when you can to file.
posted by wwax at 11:00 AM on September 20, 2012

Best answer: Generally speaking the party who's out the money is the one who files. So if you pay full cost of something out of pocket, you are the one who files the claim. You will need an itemized bill from the clinic, probably one that includes diagnosis codes and procedure codes - the Superbill referenced above. The insurance company should provide a claim form that you submit along with the bill.

If you are only paying a copayment, coinsurance, or deductible at the time of service, the provider will file. Then the insurance company sends you an EOB which shows if there's anything left you owe. The provider gets this information as well and will then bill you as needed.

It is weird that your clinic is acting like they don't know this, or they don't work that way, which leads me to believe they may have had trouble getting reimbursed for these bulk IUDs in the past and are fobbing that risk off on you. Hard to say without being there. You can complain to your insurance company and to your local agency that regulates medical practices.
posted by expialidocious at 1:29 PM on September 20, 2012 [1 favorite]

Response by poster: Yeah... what everyone is saying about my having to file this makes good sense, but it is totally baffling that they never told me all this, not even the fact that I would have to file. I am really scared now that I'll just have to eat this cost, which is more than I make in a week. Is there any kind of legal recourse if it turns out this can't be paid for by my insurance, since they told me that it definitely would be when they placed it?
posted by showbiz_liz at 1:59 PM on September 20, 2012

I've had this happen with a dentist who turned out to be a shadymothereffer and had to eat the cost of a crown. I'd go with the suggestion that you initiate a chargeback with the credit card company. It's pretty despicable that the office is managed this way. I would go in to the office IN PERSON and be very firm about making sure that the reimbursement process is explained to you properly and filed.

As for legal recourse, I think that some form you signed before you got your IUD places the burden on you (the patient) for anything insurance may decide not to cover even if the office tells you that it's covered. But the argument could be made in small claims court that while yes, you have responsibilities as a patient, the doctor's office does too. Document everything, this may be important if you decide you have to take it to TEN!!!
posted by loquat at 2:49 PM on September 20, 2012

Did they say specifically that they would file a claim for the device, or when they said "you would be reimbursed" were they just assuming that you knew to do it, or didn't care whether you knew or not? Either way your doctor needs to know that their office is not communicating well enough with patients.

Get a copy of the bill and send it in. I wouldn't freak out yet.
posted by bleep at 3:04 PM on September 20, 2012 [1 favorite]

Response by poster: Did they say specifically that they would file a claim for the device, or when they said "you would be reimbursed" were they just assuming that you knew to do it, or didn't care whether you knew or not?

The first three times I called back to ask about it, they told me "oh, we don't know why it hasn't been filed yet, we'll look into that!" This whole thing is just making my head spin.
posted by showbiz_liz at 6:11 AM on September 21, 2012

they told me "oh, we don't know why it hasn't been filed yet, we'll look into that!"

That was just the person getting you off the phone with minimal effort...just find the receipt and file your claim.
posted by koahiatamadl at 11:47 AM on September 21, 2012 [2 favorites]

Generally, since you are the one owed the reimbursement, you submit the bill to your insurance. If you lost it, no big deal, get another one from your doctor and make sure that it indicates clearly that it was paid in full by you. Generally they don't care about the credit card receipt or statement, just the bill from the doctor indicating that you paid.

Do not dispute this with your credit card company.

From personal experience, my health insurance company is run by idiots and if my healthcare provider submits a bill for reimbursement for me, they will cut a check to the provider and not to me. Submitting it yourself should keep that from happening.
posted by inertia at 1:54 PM on September 22, 2012

Response by poster: The receipt I was given doesn't have all the necessary information for filing a claim, so I've emailed a request to the clinic for a full reciept listing treatment codes, etc. I will then file this myself and hope for the best. I'm still kind of afraid that this was somehow a deliberate attempt to prevent me from claiming the iud on my insurance, but I am trying to remain hopeful.
posted by showbiz_liz at 10:05 AM on September 23, 2012

You know what they say. "Never attribute to malice that which is adequately explained by stupidity." This sounds way more like stupidity than malice to me.
posted by bleep at 1:19 PM on September 23, 2012

Response by poster: If anyone's still subscribed to this- I finally got them to send me the superbill (thanks quince!), and I filed with my insurer today. Weirdly enough, according to the superbill there's still a balance owed to the clinic of $800 for the procedure itself, which means that they still ought to have filed this weeks ago in order to get fully paid. They just... didn't. And since they appear to have been acting against their own interests, I'm gonna assume that this was a simple case of extraordinary incompetence. (We'll see what the insurance company says, of course...)
posted by showbiz_liz at 2:00 PM on September 25, 2012

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