On a clear, fall afternoon, Julia was stopped at an intersection near her home for a red light. Traffic was calm, without too many vehicles on the road. Without warning, she experienced what she thought was an explosion. Another driver wasn’t paying attention and slammed into the back of her vehicle. Broken glass sprayed the back of her head and she immediately felt sharp pains in her back and neck. The police and emergency medical services arrived and began caring for her.
Over the next several months, Julia’s condition improved with the help of her doctors and physical therapists. Because she had called our office shortly following the accident, we were able to help her navigate through the maze of insurance issues that she had never faced before.
Julia’s auto insurance provided for the payment of $3,000 of medical expenses incurred for the treatment of injuries sustained in the accident. Unfortunately, that $3,000 was used up very quickly. But Julia wasn’t concerned. She had health insurance coverage with a reasonable deductible and co-pay so she would be able to continue to get the treatment she required.
To her amazement, Julia’s physical therapist refused to bill Julia’s health insurance. She selected this particular physical therapy clinic because they were a preferred provider under her insurance plan. Nevertheless, they told Julia that because she was making a third-party liability claim against the person who rear ended her and his insurance coverage, they didn’t need to bill her health insurance and they would instead expect full payment as part of the third-party liability settlement.
Does it matter to Julia whether her medical bills are timely submitted to her health insurance for payment? After all, won’t the liability insurance for the at-fault driver pay Julia’s medical bills anyway?
We had been in contact with the physical therapist many times demanding that they submit the bills to Julia’s health insurance company. They refused. We explained that they had the obligation to submit those bills to the health insurance company because they were a preferred provider with the insurance plan. They still refused. After many months, the physical therapy clinic actually turned the account over to a collection agent who sent Julia a threatening letter.
It does matter to Julia whether her bills are submitted to her health insurance. One of the advantages of having such coverage and choosing a preferred provider is that Julia gets the benefits of the contractual arrangements between the insurance plan and the provider. The provider agreed to accept a certain amount as payment in full for each procedure. The difference between what was billed and what was paid is adjusted off. For example, if the provider and the insurance plan agree that the plan will pay $60 for a particular procedure, and the provider charges $100, the $40 difference is adjusted off.
In Julia’s case, these adjustments would amount to thousands of dollars. The physical therapy clinic understood this and didn’t feel that they should have to accept the contractual amount to which they previously agreed as payment in full.
Once Julia’s account was turned over to collections, we were forced to take formal action. We first contacted the collection agent and explained that they were in violation of the Fair Debt Collection Practices Act and other federal and state statutes. We explained that their client, the physical therapy clinic, had failed to bill available insurance and the debt amount wasn’t yet determined. The collection agent agreed and immediately withdrew their claim.
We also contacted the legal counsel for the insurance plan. They were outraged that a preferred provider would violate the terms of their provider agreement and send a patient’s account to collections. The insurance plan immediately contacted the provider and threatened termination of their contractual agreement if the therapy clinic didn’t immediately submit the bills for payment.
Finally, we were able to get past the billing personnel for the physical therapy clinic and speak with their legal counsel. For the first time, they finally agreed to do what they should have done months previously. They submitted the bills to the insurance plan for payment.
The underlying claim against the insurance company for the man responsible for the accident was actually the easiest part of Julia’s case. She had no idea that the real battle would be against her own physical therapist. Several times, she was tempted to give in and just pay the therapy bills in full. In the end, she was grateful for our involvement in helping her get the result to which she was entitled.