Legal

Ask a lawyer and get answers to your legal questions

Ask a Lawyer,
Get an Answer ASAP!

When a person goes in for an outpatient surgical procedure…

Customer Question
When a person goes...

When a person goes in for an outpatient surgical procedure and the healthcare provider accepts your medicare coverage on assignment as well as your Supplemental Insurance policy, is it up to the healthcare provider to accept what is paid by the policies? Is it up to the healthcare provider to inform the patient if something is not covered or if something is not covered? Too bad as assignment was accepted and the patient is not liable for something Medicare will not pay for so the supplemental policy does not have to pay anything either and the patient is off the hook?

Lawyer's Assistant: What state are you in? It matters because laws vary by location.

Tennessee

Lawyer's Assistant: Has anything been filed or reported?

I have been dealing with this for months with documentation. $240.00 were for photos of my right eye and at the bottom the claim it states that the provider was not qualified to receive medicare payments. The other was $1845.00 for surgery to remove the eye lid caused by Graves Disease to correct an eye muscle. It says Medicare did not approve the charge. I believe it was coded wrong or if was considered an elective procedure should I have been informed on the front end? The Doctor billed for the procedure with no reimbursement and the facility billed for the procedure and received reimbursement. Both describe the procedure as "Surgery to move the eyelid". The doctor billed for $1,845.00 with no reimbursement and the facility billed $3,150.00 with reimbursement of $368.55. $294.84 Medicare $73.71 from supplemental policy. I thought the doctor needs to re-code the procedure but it seems easier for them to try and collect from a senior citizen on social security with a part-time job.

Lawyer's Assistant: Anything else you want the lawyer to know before I connect you?

No? I am a semi-retired pharmacist and I think they are too lazy to re-submit the claim with the proper code to get reimbursement. I just keep getting the run around and today I get a letter from a collection agency for reimbursement and I am writing to them with disgust because lazy accounts receivable or payable departments would rather intimidate me with a collection agency than do their job.

Submitted: 10 months ago.Category: Legal
Show More
Show Less
Ask Your Own Legal Question
Customer reply replied 10 months ago
Should I call Medicare myself to ask them why the Doctor did not receive payment of any kind while the facility where the outpatient surgery was done did receive payment. Both bills were described with identical wording "Surgery to move the eye lid". I realize that in healthcare reimbursement is often based on the "coding" of a procedure and my supplemental policy which sent me information on what medicare covered and what portion they paid for other charges on my bill summary just made the statement "Medicare did not approve the charge". I realize that physicians are busy and all they are concerned about is doing the procedure and have no time to worry about payment. What irks me is that I know claims can be re-filed and "coded" differently to maximize reimbursement. Someone is capable of doing this but who in this Physician Group will take the time is the frustrating question without an answer? I just think whoever is responsible for obtaining reimbursement for services performed by this physician group could care less and it is much easier for them to drop the ball or "kick The Can" down the road to me instead of doing their job. Who cares? Just send out a bill as it does not concern me so why should I care?(that is the responsible parties attitude in that physician group). I have even sent a copy of the bill asking them why the facility was paid and the doctor was not. Do you think they could respond in writing to my inquiry? That would mean they would have to respond to a legitimate question and someone would actually have to come up with a suitable answer. Instead of looking into the matter, it is much easier to ignore my inquiry and just send the bills to a collection agency. I understand what goes on in healthcare as I have worked and dealt with reimbursement in the past. I do not know who in that physician group is responsible but they have my information so they cannot plead ignorance. I am going to call Medicare and then I am going directly to the person responsible in that group who is ultimately responsible and demand that they be fired by whoever they report to. They are completely aware of my inquiry since February 2, 2017 and they have not been ignored by me and have all of the facts with no response from them. The thrust of my question to you is that when my medicare and supplemental policy was accepted on assignment in the State of Tennessee it was offered by me and accepted by them in good faith of both parties and all that they would be reimbursed for is what the policies covered and I was responsible for nothing more or nothing less. And if so in retrospect was it up to them to inform me or to spring charges on me on the front end say they could not accept "assignment" on my Medicare and United Health Supplemental Policy thru AARP. What is so frustrating is what I asking you I asked of them with no response. It is not as though I have ignored there bills hoping that by some magical "fairy dust" they would stop. I have made copies given them to two physicians mailed my inquiry to the physician group hoping it would find its way to a responsible party who would answer me. They cannot plead ignorance when I walk into their office and have a sit down discussion which I plan on doing today as I have had the run around long enough. The collection agency was the last straw in my normally easy going temperament.
Answered in 12 hours by:
9/6/2017
Lawyer: Phillips Esq., Attorney-at-Law replied 10 months ago
Phillips Esq.
Phillips Esq., Attorney-at-Law
Category: Legal
Satisfied Customers: 22,381
Experience: B.A.; M.B.A.; J.D.
Verified

Hello: This isCustomer Welcome to JustAnswer! I am reviewing your post, and I will post my response very shortly. Thank you for your patience.

Ask Your Own Legal Question
Lawyer: Phillips Esq., Attorney-at-Law replied 10 months ago

I am sorry to read about your difficulties.

First and foremost, you need to contact Medicare to find out why the facility received remibursement, but the doctor did not. You can then pass this information along to the doctor's account receivable department.

As for the doctor/facility being responsible for the payments because your insurance was accepted, regrettably, the patient is ultimately liable for the bill if the insurance does not cover the procedure. However, if you did go through the procedure on the promise that the procedure would be covered by your insurance, then you can refuse to pay the uncovered bill using the implied contract theory of detrimental reliance. That is, you would argue that but for the promise that was made to you, you would not have gone through the procedure and incurred the bill. So, you are not responsible for the bill. The facility/doctor is responsible for the bill.

As for the collections agency, you should send them a cease and desist letter to stop contacting you immediately with regard to the bill because you dispute the validity of the bill. Once you do this, the collector is prohibited by Fair Debt Collection Practices Act from contacting you with regard to the bill. However, they can file lawsuit to try to recover the debt. But if you are on Social Security and have only a part-time job, chances of them collecting are little to zero. Your Social Security payments are 100 % exempt from garnishment. Only 25% of your net wages can be garnished.

Best wishes,

A positive rating to my response is appreciated so that I can receive credit for responding to your post. There is no additional cost to you for giving a positive rating.

Thank you for your cooperation.

Ask Your Own Legal Question
Customer reply replied 10 months ago
Thank you for your response counselor. I appreciate your service and your sage advice. I will use your service again if necessary. Take care and may God bless you for your service is my prayer for you.
Lawyer: Phillips Esq., Attorney-at-Law replied 10 months ago

You are quite Welcome!

A positive rating to my response is appreciated.

Than you for your cooperation.

Ask Your Own Legal Question
Was this answer helpful?

How JustAnswer works

step-image
Describe your issueThe assistant will guide you
step-image
Chat 1:1 with a lawyerLicensed Experts are available 24/7
step-image
100% satisfaction guaranteeGet all the answers you need
Ask Phillips Esq. Your Own Question
Phillips Esq.
Phillips Esq.
Phillips Esq., Attorney-at-Law
Category: Legal
Satisfied Customers: 22,381
22,381 Satisfied Customers
Experience: B.A.; M.B.A.; J.D.

Phillips Esq. is online now

A new question is answered every 9 seconds

How JustAnswer works:

  • Ask an ExpertExperts are full of valuable knowledge and are ready to help with any question. Credentials confirmed by a Fortune 500 verification firm.
  • Get a Professional AnswerVia email, text message, or notification as you wait on our site. Ask follow up questions if you need to.
  • 100% Satisfaction GuaranteeRate the answer you receive.

JustAnswer in the News:

Ask-a-doc Web sites: If you've got a quick question, you can try to get an answer from sites that say they have various specialists on hand to give quick answers... Justanswer.com.
JustAnswer.com...has seen a spike since October in legal questions from readers about layoffs, unemployment and severance.
Web sites like justanswer.com/legal
...leave nothing to chance.
Traffic on JustAnswer rose 14 percent...and had nearly 400,000 page views in 30 days...inquiries related to stress, high blood pressure, drinking and heart pain jumped 33 percent.
Tory Johnson, GMA Workplace Contributor, discusses work-from-home jobs, such as JustAnswer in which verified Experts answer people’s questions.
I will tell you that...the things you have to go through to be an Expert are quite rigorous.

What Customers are Saying:

Mr. Kaplun clearly had an exceptional understanding of the issue and was able to explain it concisely. I would recommend JustAnswer to anyone. Great service that lives up to its promises!

Gary B.Edmond, OK

My Expert was fast and seemed to have the answer to my taser question at the tips of her fingers. Communication was excellent. I left feeling confident in her answer.

EricRedwood City, CA

I am very pleased with JustAnswer as a place to go for divorce or criminal law knowledge and insight.

MichaelWichita, KS

PaulMJD helped me with questions I had regarding an urgent legal matter. His answers were excellent.

Three H.Houston, TX

Anne was extremely helpful. Her information put me in the right direction for action that kept me legal, possible saving me a ton of money in the future. Thank you again, Anne!!

ElaineAtlanta, GA

It worked great. I had the facts and I presented them to my ex-landlord and she folded and returned my deposit. The 50 bucks I spent with you solved my problem.

TonyApopka, FL

Not only did he answer my Michigan divorce question but was also able to help me out with it, too. I have since won my legal case on this matter and thank you so much for it.

LeeMichigan

< Previous | Next >

Meet the Experts:

Ely

Ely

Counselor at Law

24,657 satisfied customers

Private practice with focus on family, criminal, PI, consumer protection, and business consultation.

INFOLAWYER

INFOLAWYER

Attorney

22,408 satisfied customers

Licensed attorney helping individuals and businesses

JPEsq

JPEsq

Attorney

2,132 satisfied customers

Experience as general attorney, in house counsel, SSDI, Family Law attorney, and law professor

Law Educator, Esq.

Law Educator, Esq.

Attorney

44,066 satisfied customers

JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law

Ellen

Ellen

Lawyer, Consultant

8,238 satisfied customers

25 years of experience helping people like you.

Guillermo Senmartin

Guillermo Senmartin

Lawyer

300 satisfied customers

Principal Attorney at Guillermo J. Senmartin, P.A.

Dimitry K., Esq.

Dimitry K., Esq.

Attorney

17,183 satisfied customers

Multiple jurisdictions, specialize in business/contract disputes, estate creation and administration.

< Previous | Next >

Related Legal Questions
My mother-in-law who is 90 suffered an ankle fracture 4 months
My mother-in-law who is 90 suffered an ankle fracture 4 months ago. She had ankle surgery by an orthopedic doctor with metal hardware put in to keep the ankle together. At the end of the surgery her s… read more
Phillips Esq.
Phillips Esq.
Attorney-at-Law
JD
22,381 satisfied customers
On November 21 2013 I was admitted into the hospital via emergency
On November 21 2013 I was admitted into the hospital via emergency with a severe bacterial infection in my hand. Upon entering I gave all my insurance information to the Hospital. In the emergency roo… read more
Gerald, Esq
Gerald, Esq
Juris Doctor
138 satisfied customers
Unless a supplemental policy specifically states otherwise,
Unless a supplemental policy specifically states otherwise, the most it will cover are the Medicare deductibles ($147 outpatient and $1,187 hospitalization) and the 20 percent co-insurance. Supplement… read more
Stephanie O Joy, Esq
Stephanie O Joy, Esq
Managing Lawyer/Advocate
Doctoral Degree
3,286 satisfied customers
I had stent surgery at Mon Gen Hosp in May 2013. I was required
I had stent surgery at Mon Gen Hosp in May 2013. I was required to stay over night and was hookup to medicines and was released the next day. I had a private room, meals and medicine provided while th… read more
CalAttorney2
CalAttorney2
Attorney
Doctoral Degree
8,845 satisfied customers
I am a retired person and has full coverage for health through
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… read more
Legalease
Legalease
Attorney At Law
Doctor of Law w/ highest honors
15,719 satisfied customers
How can a physician discover whether a medical procedure can
How can a physician discover whether a medical procedure can be legally performed in the office setting?… read more
socrateaser
socrateaser
1,452 satisfied customers
I had an arthrosopy on my hand under full anesthesia. It relieved
I had an arthrosopy on my hand under full anesthesia. It relieved me of the pain and made my hand functional again. The provider filed the claim on my behalf and an appeal. Medicare's appeal decision … read more
Help4Health
Help4Health
Attorney and Counselor at Law
Doctor of Jurisprudence
31 satisfied customers
If a physician hires my company to provide marketing services
If a physician hires my company to provide marketing services that result in appointments for the physician, and he / she pays me for the services and not a percentage of any professional fees collect… read more
Sam
Sam
Attorney
Doctoral Degree
10,701 satisfied customers
In April 2011, I had rotator cuff surgery in an outpatient
In April 2011, I had rotator cuff surgery in an outpatient clinic. Before the surgery, I made the proper inquiries regarding medical insurance and was assured by BCBS as well as the surgeon that the c… read more
Delta-Lawyer
Delta-Lawyer
Doctoral Degree
3,510 satisfied customers
I have a situation that has come up regarding medicare billing,
I have a situation that has come up regarding medicare billing, and I thought that perhaps you could clarify it for me. As my company Sure Foot, Inc. is not a medicare provider, when we sell as xxxxx®… read more
Robert
Robert
Attorney
Doctoral Degree
909 satisfied customers
For a newly built outpatient/ambulatory surgery center that
For a newly built outpatient/ambulatory surgery center that is being prepped to undergo an accreditation survey by AAAHC, per Health and Safety Code for California, section 1248.1, states that an orga… read more
Richard - Bizlaw
Richard - Bizlaw
Juris Doctor
3,770 satisfied customers
Who can qualify to be a ASC under 10 NYCRR 755.1 And who
Who can qualify to be a "ASC" under 10 NYCRR 755.1? And who can qualify to be a brithing center (10 NYCRR 715.4)? what are penalities for violating these rules?… read more
Ray
Ray
Lawyer
Doctoral Degree
33,357 satisfied customers
I am retired military. Under the law, my primary coverage
I am retired military. Under the law, my primary coverage is Medicare Part A and B. My Secondary coverage is Tricare for Life. The doctors bill Medicare, Medicare sets the payable amount, and pays rou… read more
Anne_C
Anne_C
Attorney
Doctoral Degree
14 satisfied customers
REVISED LIABILITY FOR DOCTORS FEES and CONTRACT LAW
QUESTION IS ON MEDICAL INSURANCE COVERAGE AND CONTRACT LAW I have general medical insurance coverage under a popular Blue Cross Blue Shield of Massachussetts Preferred Provider Plan (PPO). Under this … read more
Ray
Ray
Lawyer
Doctoral Degree
33,357 satisfied customers
After an accidental fall resulting in facial plastic surgery,
After an accidental fall resulting in facial plastic surgery, am I responsible for the out of network plastics surgeons fees? I was in an in network hospital where the plastic surgeon was on emergency… read more
NA
NA
183 satisfied customers
I had an MRI done as an outpatient at Loma Linda University.
I had an MRI done as an outpatient at Loma Linda University. My bill was (for the procedure only) $2,790.00 of wich my insurance paid $156.00. I have been billed separately for the doctors/techs that … read more
FLACORPLAWYER
FLACORPLAWYER
Doctoral Degree
1,750 satisfied customers
if you move to another state do you stil have to pay for a ...
if you move to another state do you stil have to pay for a collection agency bil from a healthcare facility?… read more
Ellen
Ellen
Lawyer, Consultant
Doctoral Degree
8,238 satisfied customers
A friends husband died at age 60. In Illinois, unlike
A friend's husband died at age 60. In Illinois, unlike many other states, he was turned down for Medicare supplemental insurance because he was under 65.The law in Illinois has recently been changed t… read more
Roger
Roger
Litigation Attorney
Doctoral Degree
26,935 satisfied customers

DISCLAIMER: Answers from Experts on JustAnswer are not substitutes for the advice of an attorney. JustAnswer is a public forum and questions and responses are not private or confidential or protected by the attorney-client privilege. The Expert above is not your attorney, and the response above is not legal advice. You should not read this response to propose specific action or address specific circumstances, but only to give you a sense of general principles of law that might affect the situation you describe. Application of these general principles to particular circumstances must be done by a lawyer who has spoken with you in confidence, learned all relevant information, and explored various options. Before acting on these general principles, you should hire a lawyer licensed to practice law in the jurisdiction to which your question pertains.

The responses above are from individual Experts, not JustAnswer. The site and services are provided “as is”. To view the verified credential of an Expert, click on the “Verified” symbol in the Expert’s profile. This site is not for emergency questions which should be directed immediately by telephone or in-person to qualified professionals. Please carefully read the Terms of Service (last updated February 8, 2012).

DISCLAIMER: Answers from Experts on JustAnswer are not substitutes for the advice of an attorney. JustAnswer is a public forum and questions and responses are not private or confidential or protected by the attorney-client privilege. The Expert above is not your attorney, and the response above is not legal advice. You should not read this response to propose specific action or address specific circumstances, but only to give you a sense of general principles of law that might affect the situation you describe. Application of these general principles to particular circumstances must be done by a lawyer who has spoken with you in confidence, learned all relevant information, and explored various options. Before acting on these general principles, you should hire a lawyer licensed to practice law in the jurisdiction to which your question pertains.

The responses above are from individual Experts, not JustAnswer. The site and services are provided “as is”. To view the verified credential of an Expert, click on the “Verified” symbol in the Expert’s profile. This site is not for emergency questions which should be directed immediately by telephone or in-person to qualified professionals. Please carefully read the Terms of Service (last updated February 8, 2012).

Show MoreShow Less

Ask Your Question

x