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Legalease
Legalease, Lawyer
Category: Legal
Satisfied Customers: 14503
Experience:  15 years exp all aspects of general law
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I am a retired person and has full coverage for health through

Resolved Question:

I am a retired person and has full coverage for health through Medicare advantage plan and supplemental United health plan. On 4/18/11 I had lab tests done after my insurance coverage was confirmed by the lab. In Nov.11 I received a bill for about $1500. I called Medicare and they told me there is no claim(bill) received from the lab till today which is well over 90 days time limit They told me to inform the lab to submit the claim which I did and supplied my insurance details. Few months later the Lab. billing office called and asked for insurance information which I gave second time.This went on till 6/25/13 when I called Medicare to get to the bottom of this problem. Medicare told me the following- 1. You are covered fully by Medicare and you should not have received the bill in the first place. 2. The claim was denied because it was incorrectly made. 3. You are not responsible for the bill so do not pay.
The lab. holds me responsible for the bills and have sent my account to collection agency. I gave them my explanation in writting for dispute but they insist on payment or else it will be reported to credit agency. I feel I do not have to pay for the labs negligence. Please let me know what I need to do. Thank you. M.P.
Submitted: 1 year ago.
Category: Legal
Expert:  Legalease replied 1 year ago.

Hello there M.P. --

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I am sorry that this is happening to you -- it is aggravation that you do not need when it could have and should have been avoided in the first place.

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Can you tell me whether or not Medicare will still pay the claim, despite the lateness of the claim, if the lab submits it correctly OR is Medicare now telling them "too bad, you know the rules and the claim is too late to be paid ??" (which still does not make you respnsible for payments, but I will get to that in my answer). Any other information you can think of regarding this situation will be helpful to me in researching and writing up an answer for you so feel free to either simply answer my question in a response box or answer the question and elaborate anywhere that you feel it may be needed.

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MARY

Customer: replied 1 year ago.

medicare refused an appeal by the lab. because it was late.


On the day of these tests, I was asked to sign some forms which is common. If there was any thing about payment I do not remember. But I am fully covered by Medicare. It is lab billing dept. duty to send the claim on time which they did not. I should not be made to pay for that .

Expert:  Legalease replied 1 year ago.

Hello again Madhukar --

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You are absolutely NOT responsible for this bill and that is where I come in -- I am going to give you several suggestions regarding how to deal with these matters to get collections off your back and your credit history restored. First, you should file complaints with the various federal and state agencies that handle complaint against medicare providers -- particularly within the Medicare system (you never know -- this doctor's office may not be just making stupid mistakes like this -- they might also be doing something criminally illegal like padding bills or overbilling and so your complaint will most likely result in a larger investigation into the billing practices of this doctor and/or his doctor group. First, here is a link to the Medicare complaint pages -- http://www.medicare.gov/claims-and-appeals/file-a-complaint/complaints.html - you can file a complaint with Medicare directly for the mess that has happened here and Medicare should investigate the matter (the way it works is that Medicare typically does not take any action against the medical provider if they receive a complaint about the provider here and there or every now and then -- but when they receive many complaints against a particular provider they will take action against the provider at that point). Next, you should also file a billing complaint with the California Medical Board Dept of Consumer affairs -- there are many occasions where the Dept of Consumer Affairs have been able to intervene on behalf of a patient and take care of the problematic billing issues so that the doctor's offices will stop their collection efforts and any reporting to the credit bureaus. Here is a link to the CA healthcare advocates website where they set forth this complaint process and they have links to the complaint form and all contact information for the California Medical Dept -- Division of Consumer Affairs -- http://www.cahealthadvocates.org/news/billing/2007/got.html#physicians . Finally, if you suspect this doctor's office of something more than stupidity in their billing practices -- such as fraud -- you should also file a complaint with the Attorney General's office California -- they are the chief law enforcement agency in the state of CA and can open the case as a criminal matter if they believe that there is any evidence or enough evidence of fraud and misrepresentation on the party of the doctor's office (I tend to lean towards incompetence on the part of the doctor's offices if this is only an occasional error -- but Medicare and the CA Medical Board / Consumer Affairs will be able to spot any trends/patterns that the doctor's offices may have dating back at least 10 years). Here is a link to the complaint form for the Attorney General's offices in CA (there are instructions on how to complete these forms and contact information on the first few pages of the website). http://oag.ca.gov/contact/consumer-complaint-against-business-or-company

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Now, once you have all of these complaints in motion and you have determined whether or not the CA Medical Board / Consumer Affairs can get the doctors office to pull the invoice back from collections and to stop reporting these matters to the Credit bureaus you can make an additional decision at that point whether or not to take separate legal action against the doctors' offices. You can easily take this matter into small claims court in CA without using an attorney -- the cost is minimal and you can get the exact forms that you need from either the clerk's office at the county civil courthouse or online at the CA Superior Court website (I will provide you with the exact web link at the end of this paragraph). You can sue for up to $7500 in small claims court. Because there is a monetary amount in controversy in this case you can sue the doctor's office in a civil small claims action for negligent billing practices -- you make a brief summary on the court form for small claims of the case -- something like the following will be sufficient (I am actually not supposed to write court filing language for customers because that may be seen as going beyond an education service website -- however, I find this situation that you are in offensive (that they are pursuing YOU for this payment that they messed up -- and I want to make sure that you get your claims down in the small claims paperwork correctly and clearly so the court knows EXACTLY what relief you are seeking overall)........

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So, here is the suggested language for the section in the paperwork where you must make a STATEMENT OF THE CLAIM / CASE ---------------------

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"Defendants negligently failed to invoice certain lab procedures and services correctly to the U.S. Department of Health and Human Services (DHHS) Medicare insurance program for laboratory services and procedures ordered by the Defendant doctor and performed by the Defendant Laboratory. Specifically, the Defendants employees were negligent when seeking reimbursement for the laboratory / medical services from Medicare because they failed to provide Medicare with certain required information regarding the Plaintiff Patient in order for the claim for laboratory services to be accepted and paid by Medicare. This negligence continued through XXXX months and several separate invoice filings to Medicare by the Defendants, escalating to a point where the Defendants exceeded the time limit / deadline for filing payment claims for they type of laboratory procedures received by the Plaintiff. Presently, because the invoices remain unpaid by Medicare and rejected due to the violation of time limits, Defendant Laboratory has sent an invoice / bill for these services to the Plaintiff and is presently demanding payment thorugh various tactics such as annoying and harassing collection agency calls and letters AND placing a negative report to the three major U.S. credit reporting agencies due to what the Defendant Laboratory is claiming is the "Plaintiff Patient's failure to pay for laboratory services rendered" . Defendant Laboratory's request for payment from the Plaintiff Patient under these circumstances is incorrect and unjustified because the reason why the Defendant Laboratory has NOT been paid to date is due to their own negligence in incorrectly preparing and submitting the required forms to Medicare. Therefore, the Plaintiff Patient hereby requests that this court order the following relief in these matters: (1) that the Defendant Laboratory or the Defendant Doctor pay the monetary charges of $$ 1500 to the Defendant Laboratory to completely wipe out any invoice that may exist against the Plaintiff Patients account, (2) that the Defendants cease & desist from all collection activity into these matters, and (3) that the Defendants write to the three major credit reporting agencies in the U.S. to reverse any adverse reports that they may have made to the credit reporting agencies against your credit rating.

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Here is the link to the website for the superior courts of CA where you can get immediate instructions on how to file a small claims case and there are links to the actual forms that you need to use to make the filing at the court -- http://www.courts.ca.gov/selfhelp-smallclaims.htm

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Finally, there is one last thing that you should do to pull all of this together -- you should prepare a chronological timeline of events in this matter from the date you went to the doctor and he ordered the test to the date you made this court filing. You should list dates, times, method of communications, any persons present and/or who you spoke with and then what happened on that particular occasion. By preparing the journal / timeline and presenting it to the court, the judge will most likely see it as a chronological timeline of how things happened in the case and will admit it into evidence for the court's review. That should show the judge clearly what happened here and the court should find quickly in your favor.

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I hope that all of this helps -- please let me know if you have any further questions.

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MARY

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Please press the 3rd, 4th or 5th smile face below this ANSWER box so I will be paid for my time. I am paid NOTHING unless you press a positive rating below. Pressing the 3rd, 4th or 5th smile face below (a positive rating) will NOT cost you any additional money -- it simply acts as a trigger to Just Answer to pay me for my time !!! BONUSES are always welcome and a BONUS box will appear after you press a positive rating so that you may enter a bonus as you see fit for the research and links that I provided for you tonight. THANK YOU VERY MUCH !!!

Customer: replied 12 months ago.

Thank you for your prompt response. I will follow your advise and write to consumer's dept and attorney generals office in the next few days. I have questions- 1. do you have any idea as to how long it will take to get a response from these departments?


2. Should I write/inform the collection agency that I have sent a complaint to these agencies?


3. You have a free one month service. Does that means I can contact you during this time? MPSmiletitle="Smile"/>

Expert:  Legalease replied 12 months ago.

Hello again Madhukar -

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Yes, tell the collection agency that you have reported these matters to the consumer afffairs department and the attorney general's office -- it might make them leave you alone for the time being until the matter is straightened out. These agencies typically take about 30 days to review a case and get back to you -- give or take a week. However, if they are slow in acting or decide to wait until they receive more complaints about this provider before making a move against them then you should seriously consider the small claims actions against the doctor and the lab. Such a court action will stop everything dead in its tracks and you will win the matter in court.

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If you have a free month then you can ask questions for an additional month (you should ask them in new, separate questions). However-- you have to press a positive rating - the 3rd, 4th or 5th smile face below -- underneath this ANSWER box so that I will be paid for my time helping you on this question. Your payment arrangement with the website has nothing to do with me and the answer I gave you above. Pressing a positive rating below will NOT cost you any more money or affect your free month -- it just tells the website to pay me for my time because you are satisfied with the answers you received (I will never be paid anything by the website unless you press a positive rating below).

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THANK YOU VERY MUCH

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MARY

Legalease, Lawyer
Category: Legal
Satisfied Customers: 14503
Experience: 15 years exp all aspects of general law
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