My insurance denied a medical bill claim for not being filed on time. Am I responsible?

My insurance denied a medical bill claim for not being filed on time. Am I responsible?
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I went to the ER and provided them at the time of service with my insurance card and they made a copy of it. The hospital billed my insurance for the ER visit and got paid. However, the doctors in the ER, who billed my insurance separately, did not get paid. They contacted me for the first time after 5 months asking for the full amount. I checked with my insurance and they said they have never received a claim. Turns out the ER doctors billed the wrong insurance company. I gave them the correct insurance information and they submitted a new claim a month later but it was denied for being late. The provider once again billed me for the full amount, I contacted my insurance, and they asked the provider to send an appeal. The provider sent an appeal. Now a year later the provider has contacted me again for the full amount because the appeal was denied. This happened in NJ. The EOB from the provider says 157- Proof of loss was not submitted timely as outlined in the Policy.
Patient Balance: Co-pay, Policy Deductible, Co-Insurance & All Amounts Over Policy Limits.
Am I responsible for this balance, it is clearly the doctor’s fault for first filing the claim to the wrong insurance company, waiting 5 months to contact me, then another month to file it with with the right company. What are my options?


Oh no!  So many mistakes are made in medical billing---and they always become our headache instead of the provider!

Have you spoken to the business manager of the ER doctor's group?  Sometimes, you have to go up the chain of command and keep asking (nicely, but assertively) if they can dismiss your bill based on their mistake.  Most ER doctor groups keep merging, so it might take a little internet searching to discover who the main owner of the group might be---but sometimes that can pay off by getting to the top office to resolve this issue.

You might even phrase as "thought you'd like to know" since sometimes the top office doesn't know about mistakes on the local level. 

You might also speak with the hospital's business office/management to inform them that one of their patients experienced billing mistakes with the ER group that they contract for their emergency services.  Most hospitals realize they are in a competitive market (especially with all the free-standing clinics popping up) and will not be happy that their contracted ER doctor group is so sloppy in its billing business practice.

Also, here in Texas the insurance companies are regulated by our state insurance regulators.  It might be worth a call to your NJ state insurance regulation office to double check the "timeliness" issue---sometimes mistakes are made there as well....and if you have the official word from the state insurance department, you'll have all the facts in hand to see if you have any recourse there.

Good luck!  It's terrible having to deal with billing issues---but even worse to pay medical bills that aren't our responsibility in the first place!


Here are 3 additional approaches:

1. If the provider billing you now is contracted with the insurance, they cannot bill you unless the insurance EOB shows they can. Most provider contracts with insurances prohibit billing the patient for untimely claims. Check the EOB, and call the insurance to report improper billing if this is the case.
The insurance will contact the provider and order them to stop billing you. If this is unsuccessful, after 30 days the insurance can start more aggressive action leading to a potential contract termination.

2. Ask for a copy of the “registration form” from the facility (you might be able to download it from the online patient portal). This document is what all related providers use to bill patients. This is not what you may filled out, but the print out from your hospital chart. If the correct insurance is listed, file a complaint with the ER group’s managing physician or manager, showing the proof that the info was available in a timely manner. I would threaten them with filing a complaint with the Federal Trade Commission if they refuse to write off the balance.

3. If the form is blank, or incorrect, file an appeal with the insurance. You would need to certify that you gave the correct insurance info on a specific date, that you are asking the insurance to pay the charges, and that the office was given incorrect info from the facility, hence the delay. Add a copy of the incorrect registration form and of the EOB from the incorrectly billed insurance to establish a timeline and show it was not their fault. I just won one of those for a client.
The provider may not go through this trouble, but writing a letter is worth saving that kind of money. The insurance website or phone representative can direct you to the appeal form and mailing address.

Wishing you success,

Martine Brousse


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