Making Sure a Claim for Benefits Has Been Filed With Your Healthcare Insurer

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Many of our clients are victims of automobile or trucking collisions and end up going to the hospital emergency room to get treatment for their injuries.  The hospital might ask you about your health insurance, but usually, once they learn you were in a collision, they don’t file the claim with your health insurer.  They do this because when they submit a claim through a health insurer, the insurer only pays them a portion of the total amount of your bill; this is because health insurers often have contractual agreements with hospitals that require the hospital to accept a lower payment for services (an insurance “adjustment”).

Instead of submitting your bill through your health insurer, the hospital will file a lien against your injury claim for the full amount of their bill.  By law you must pay back the lien from any proceeds of your case before any of the money goes to you. The end result? The hospital pockets the money that should have gone to you.

The good news is this can be avoided. Let’s take a look at the following examples.

Example A:

Bob, who has ABC health insurance, is hit by a tractor trailer. Bob goes to the ER for treatment. Bob tells the hospital he has ABC health insurance. The hospital charges $1,000 for Bob’s treatment, but opts not to submit the claim to ABC. Instead, the hospital files a lien for the $1,000 Bob owes. Therefore, no insurance payments are made, and Bob is personally responsible for the full $1,000. When Bob settles his case or wins a judgment, he must repay the hospital the full $1,000.

Example B:

Bob, who has ABC health insurance, is hit by a tractor trailer. Bob goes to the ER for treatment. Bob tells the hospital he has ABC health insurance. The hospital charges $1,000 for Bob’s treatment, but opts not to submit the claim to ABC. Bob realizes this, and promptly submits the claim on his own to ABC. Since ABC has an insurance contract with the hospital, ABC “adjusts” Bob’s bill to their contracted rate of $500, and pays the hospital that amount in full satisfaction of Bob’s bill. When Bob settles his case or wins a judgment, he must repay ABC insurance $500.

You can see from these examples why it is important that if you have health insurance, you make sure your hospital bills are promptly submitted to your health insurer. DO NOT rely on the hospital to do file a claim for you—you should contact your insurer directly to see if a claim has been submitted. If a claim has not been filed, you should submit the bills yourself as soon as possible.

It is also important to note that most health insurance plans have a time limit within which you must submit a claim for services. Typically a claim must be submitted within a few months after the date of treatment. If the claim is submitted after that deadline, it may not be covered and you will be responsible for the full amount of the bill.

The foregoing answer is not specific legal advice and is merely a general overview. You are advised to consult a lawyer to address your specific situation. Feel free to send comments or questions to: steve@aa-legal.com of Apolinsky & Associates, LLC, or call (404) 377-9191.

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