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MDLaw
MDLaw, Attorney
Category: Business Law
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Experience:  Experience in business law, contract law and related matters.
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Is an "in network" physician required to submit an insurance

Resolved Question:

Is an "in network" physician required to submit an insurance claim for an in network patient who sees the physician in his office? I am pretty sure the answer is that if the physician is in network for the insurance company, her office is required to submit the claim, but I just wanted to check.
Submitted: 9 months ago.
Category: Business Law
Expert:  MDLaw replied 9 months ago.
Hello and thank you for using the JA website. I look forward to assisting you today with your legal question. In order to do so, however, I need a little more information from you. First, are you asking if there is a law that requires a physician to fill out an insurance claim for an in-network patient or are you asking if it is legal for the insurance company to require such?

Customer: replied 9 months ago.

The doctor is an "in network" physician, so she definitely has a contract with the insurance company to see and treat patients who have the insurance. The question is whether the doctor's office can require the patient to file the insurance claim, rather than filing the claim for the patient. I believe the doctor is required to file the claim? Am I right about this, or do I have to file my own claim?

Expert:  MDLaw replied 9 months ago.
Thank you for the additional information, Jane. Just so that I answer the question you are asking though, are you asking if there is a law that requires the doctor to file a claim? If that is your question, there is no law that addresses the issue at all. It is completely up to either the contract the doctor has with the insurance company and/or the doctor's office policy. In other words, it is perfectly within the law and legal for a doctor's office to require that the patient submit their own insurance claim to their insurance company. I think this is what you are asking, correct? If this has answered your question, let me know. If you need any additional clarification or if there is more information that you need from me, please reply so that we can continue our conversation. Thank you in advance!

Customer: replied 9 months ago.

I thought if the doctor was part of the insurance network, and agreed to take patients from that network (in this case a PPO network), that to become part of the insurance network the doctor had to agree to file claims for her services with that insurance company. However, it sounds from what you said like it is a question of what contractual obligations the doctor has with that insurance company. Is it possible that an insurance company would allow a doctor to participate with the insurance but at the same time say that the patient would have to file the claim?

Expert:  MDLaw replied 9 months ago.
Yes, that would be a contractual issue. For example, if the contract between the doctor and the insurance company required the doctor to do the claims and the doctor did not, then the doctor would be violating the contract but not any laws. If, however, the contract did not require the doctor to fill out the claims, then the doctor would not be violating the contract.

Yes, it is entirely possible that an insurance company would allow a doctor to participate but yet have the patient fill out the claims. I've seen this many times. Usually, an in-network doctor will have a co-pay, for example, but they don't know at the time of service whether or not a patient has met the deductible and so they require the patients to fill out any paperwork.

MDLaw, Attorney
Category: Business Law
Satisfied Customers: 5807
Experience: Experience in business law, contract law and related matters.
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