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I have a legal question about doctor bills. I had a breast…

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I have a legal...

I have a legal question about doctor bills. I had a breast biopsy last summer. I presented my insurance card to my doctor & the procedure what completed. A few months later, I received a $8,000 bill. My insurance did not cover the procedure. Is the doctors office required to give me a breakdown of how much the procedure will cost? I was blindsided by this.

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

WA

Lawyer's Assistant: What steps have you taken so far?

I've set up a payment plan to pay it. I don't want to be sent to collections but the more I think about it the more I feel like something was not done properly on their end.

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

No, that's about it.

Submitted: 4 months ago.Category: Legal
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Answered in 16 minutes by:
3/16/2018
Lawyer: Attorney Wendy, Lawyer replied 4 months ago
Attorney Wendy
Category: Legal
Satisfied Customers: 1,190
Experience: Member at Keefer & Keefer LLC
Verified

Hello. My name is ***** ***** I am an attorney. I am so sorry you are in this situation. I can only imagine the shock of receiving such a bill. In most states, there is no obligation for health care providers to inform you of what will be covered by insurance and what will not (indeed, it is likely that most doctors and non-hospital billing practices have no real idea how much things cost or what is normally covered). There is some level of duty for a doctor to inform a patient if the doctor simply does not participate in plans of the patient's insurer; but this would not apply to situations where they do participate but the particular insurance policy did not cover a particular procedure. You have taken good first steps to set up a payment plan; you can also attempt to negotiate down the total owed based on the failure to provide you any cost estimates prior to performing the procedure. Some states, like New York, place greater burdens on healthcare providers to give more financial information to patients prior to services, but I have not found any such requirement in Washington.

There are some stricter regulations of the actual insurance carriers in Washington and it may be that you could also request a reconsideration or appeal of the insurance company decision as well. The Patients Bill of Rights sets out the basic duty health insurance companies have to their insureds. A summary can be found here: https://www.insurance.wa.gov/patient-bill-rights

I hope this helps and, again, I am very sorry you are having to deal with this issue. If you need further assistance, please reply to this email. If I answered your question and provided excellent service, I would greatly appreciate a 5 star rating at this time.

Please note: This information is ​for educational purposes only and is not legal advice. No course of action is being proposed and no attorney-client relationship or privilege has been formed as a result of this conversation.

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Customer reply replied 4 months ago
I would not expect them to know my benefit coverage but I would expect that such a costly procedure should be disclosed to the patient as to how much they could potentially pay. Additionally, I would expect that they would have some requirements to get pre-authorizations, etc. I had to go back recently for a follow up & when I provided them my insurance card, (new/different insurance co) they immediately looked up my insurance & had trouble finding it as it was new. They would not accept me for my appointment until they verified the insurance, so it feels like there was something missed (I don't know what) in my biopsy appointment that they should be responsible for.
Lawyer: Attorney Wendy, Lawyer replied 4 months ago

I agree this seems, at least, unprofessional. I would consider - and I'm happy to help - sending a written letter to the billing department (if it is different from the main office) and the doctor's office and, especially after your most recent experience, ask that they reduce the total owed due to their failure to provide you any estimate of the cost involved. This practice, when paired with a denial of a follow-up appointment for failure to be able to verify insurance, is not the equivalent of fair patient treatment. I totally agree is seems like someone may have violated their own policies (or they may have responded as they did because your account shows an owed balance - who knows), but I haven't found any actual legal violation. Unfortunately, the majority of regulation in this industry has had more to do with what insurance companies must tell people than healthcare providers. I will look a bit more this morning to see if there is another avenue I could identify.

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