Tasha
Canton,#2Consumer Suggestion
Wed, February 11, 2004
Whenever a physician "participates" with an insurance company, there are guidelines to which they must adhere. It is the physician's responsibility to submit the claims in a timely manner and your only monetary responsibility should be your co-pay. You are correct in your assumption that if the physician never submitted the claims for the office visits, he gets to eat the charges above and beyond your co-pay amount. One recourse you would have is to notify the insurance company that his office is not complying with the terms of his agreement with them due to the fact that he is trying to charge you more than your co-pay. With regards to services he administered that are non-covered by your insurance, in this respect you need to take the initiative to know your coverage. If you are not sure it will be a covered service, don't be afraid to ask if it will be paid by your insurance and if not find out how much the cost is PRIOR to receiving the service so that you don't get "sticker shock" when you see the bill. And last but not least, is this physician aware that his office staff has not submitted any of your claims and that they are in essence "breaching" his participation agreement with the insurance company? He may need a heads-up to realize that he needs competent people to run his office and make sure that they are not putting his "status" as a health care provider in jeopardy. I hope that I have given you at least a starting point to resolving this issue. Good luck!