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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 115440
Experience:  JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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My wife was in the hospital, and a doctor sent 2 claims to

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My wife was in the hospital, and a doctor sent 2 claims to Medicare as follows: 6/09 to 6/11: total charge 288, Medicare approved: 194.67, Medicare paid: 152.61, total I may be billed: 38.94.6/08 to 6/14: total charge 512, Medicare approved 461.19, Medicare paid: 361.59, total I may be billed: 92.93.My secondary paid the total of both claims that I may be billed of 131.17.The doctor sent me a bill for the total amount of both claims that was not approved by Medicare: 154.63.The doctor accepted Medicare assignment, but is not in the network of my secondary insurance.My LA State Department of Insurance said I should file a complaint with Medicare, because the doctor is "balance billing" which is illegal as he accepted Medicare assignment.The Medicare representative gave me the run-a-round and could not help, because she only had my word the secondary paid 131.17. She said as far as she knows the bill of 154.63 might include the 131.17 he could bill me. If so, this means I need the doctor to explain 154.63 less 131.17 which is only 23.46. I explained I had the EOB from Medicare and from my secondary, and the doctor's bill in hand, but it did no good.I called the doctor's office and was told that the doctor is not associated with any insurance company and charging what Medicare did not approve was legitimate.Can the doctor legally charge me for what Medicare did not approve? If he cannot, what should I do as I already called my state department of insurance and Medicare.
The Louisiana Supreme Court recently held that patients can sue health care providers directly for violations of the state’s Balance Billing Act. See: La. Rev. Stat. 22:1871 et. seq. The LA Balance Billing Act prohibits health care providers, including doctors and hospitals, from collecting or attempting to collect from an insured patient any amount owed by the health insurer or amounts in excess of the contracted reimbursement rate between the patient’s insurance company and the provider. See: Anderson v. Ochsner Health Sys., 134 So.3d 1184 (La. 2014).
So you need to contact your doctor, since they are in violation of the law and you need to inform them they are not allowed to balance bill under the LA law and that if they refuse to correct the matter, you will pursue legal action against them.
Customer: replied 8 months ago.
34;...collecting or attempting to collect from an insured patient any amount owed by the health insurer or amounts in excess of the contracted reimbursement rate between the patient’s insurance company and the provider." I don't see how this applies to this situation, because there is no contract between this provider and any insurance company.
Thank you for your reply.
The provider has a contract with Medicare, they are an insurer.
Customer: replied 8 months ago.
The doctor's office insists this is not balance-billing, because he is not associated with any insurance company. They say they can bill what Medicare does not approve even though he accepted assignment. I see a long road ahead fighting this as I'm not sure which organization to get help from. If, in the long run, this is a case of illegal balance-billing, I will pay you.
Thank you for your reply.
The state insurance commissioner and state attorney general would be the state agencies to assist, also the Medicare Office of Inspector General. Other than that you would have to hire a local attorney, as the attorneys from this site (even though I am licensed in Louisiana and several other states) cannot represent any customer from this site.
Customer: replied 8 months ago.
I already did these things before I contacted you.The state AG's office sent me to the LA State Insurance Dept. This department said I need to file a complaint with Medicare directly. The Medicare representative connected me with what he said was the correct department. The representative in this department said she could not help me, because she did not have in hand the doctor's itemized bill showing the charge is for the amount that Medicare did not approve. I explained I had the bill in hand which showed the amount that Medicare and my secondary paid and the total amount charged. The amount I was billed is exactly the amount that Medicare did not approve. The Medicare rep said she does not know that. Maybe, the doctor was charging for something else. She said I would need to get an invoice that stated I was being charged for the unapproved amount.Please note: This is the 3rd time that I am responding and saying I will rate you and pay you if it turns out that your advice was good. I don't know how long that will be, because the doctor's office is claiming this is not illegal balance-billing, because he is not associated with any insurance company.
Thank you for your reply.
You have to send the information to Medicare office of inspector General and write your complaint to them. They are not just going to do anything on just your word. Send them the complaint and they need to investigate. If you want action then you need to send them all the information. We cannot send it for you.
Customer: replied 8 months ago.
It never entered my mind that you should represent me or send the information to Medicare. The Internet lists many divisions and subdivisions of the Medicare Office of Inspector General, and none of the brief descriptions of each even remotely match my situation. Finally, I called Medicare and asked for an address to send the information to. The rep searched for 15 minutes and could not find any. I asked for a supervisor who told me that the doctor has 1 year to correct the situation or he will be charged with a Medicare assignment violation. She said I should call back in 1 year if the situation is not resolved. As I said before, I will not rate you until this matter is settled. If it turns out that balance-billing info helps solve this, I will pay you, but the Inspector General information you provided did not help.
Thank you for your reply. Legally we have to keep reminding people we cannot represent them, do not take offense at that.
Medicare tells consumers to first report the balance billing issue with medicare to the provider and if the provider does not correct it, then you report it to your state insurance commissioner and if they do not intervene, here is the number that medicare provides to report medicare fraud, and this is considered medicare fraud, 1-***-***-****.
Customer: replied 8 months ago.
This is a follow-up to let you know that I realize you still need a rating to be paid. I am still waiting to see how this plays out. For your information, here is what has happened: I notified the office manager and billing clerk that they were involved in illegal balance-billing. They insist they are not, because he is not associated with any insurance company. I asked for a detailed, itemized bill showing exactly where the 154 comes from, because the total amount Medicare approved and said I could be billed was paid. The office manager said she would send one. A few days later the new bill arrived with the same information as the original but with two new words. The words, "Previous Balance" are now written next to the 154 I am supposed to owe. I wrote back saying my wife and I never heard of or ever used this doctor before he treated my wife in the hospital when our regular doctor was on vacation. The office manager called a few days later and said they never should have sent a bill with, "Previous Balance" on it. However, she said the doctor still insists we owe, because he is not associated with any insurance company. I said he accepted Medicare assignment and will fight this charge. That is where it stands. I filed a complaint with the LA State Board of Medical Examiners.
Again, I will rate and pay you if it turns out that this is illegal balance-billing.
Thank you for your reply.
They are associated with medicare did you tell them that too, because if they take medicare they are.
I wish you the best good luck.
Customer: replied 7 months ago.
Follow-up: I sent the office a letter that will I not pay the bill, because it is based on illegal balance-billing. I assume he will send it to collections, and, if he does, I will use that defense. I will rate you at some point in the future after this plays out. I don't know what branch of law to look under to find an attorney to defend me, but I am willing to pay a fee greater than the doctor's bill as a matter of principle.
Thank you for your reply.
Please understand, I only provide information to customers, I am not able to make people on your end do anything at all.
You would need a local consumer protection attorney or insurance law attorney.
As far as your threats about rating me at some point in the future, I am not an employee of this site I provide this service to customers because I believe many people need information without paying full legal fees, but I will not continue to do so when I believe I am being abused. I wish you the best, ***** ***** will no longer be available to assist you.
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