In Oregon does a doctor in the ppo network have to bill my ppo insurance before they bill me? ?

[adalwine]

i was seen in 2007 at the e.r. of a ppo providor. i didnt yet have my insurance card but i had the info. i called three days after the visit and gave them all the info on my card. i recieved many bills for the service so i called and gave them my insurance again, they said they never had it and that they would resend the claim. to make a long story short they never did. and i am now in small claims court. the plaintiff (rep from the collections dept) said i signed a financial responsibility agreemant regardless of insurance coverage so i need to pay. she also said they submitted a claim that was denied because the insurance said my coverage didnt start until 2008, which my insurance said never happened. i have a copy of all claims sent in, and there is no record of any claim, accepted or denied for the service. the plaintiff said that even still, the e.r. Doesnt have to bill the insurance. the e.r. Told me they take care of all billing, and i thought a ppo provider must bill the insurer before the patient. she also said that the lady i talked to at the e.r. Said i admitted to throwing the bills away as junk mail and that i dropped the ball and would pay it...which never happened? what should i do? please dont answer if you dont know the laws, im looking for actual info on oregon revised statutes, request for discoveries, small claims court info ect. I tried legal aid n they wont help in small claims.

[hillocke]

When you go to any medical professional in the United States, you sign a form saying that you are responsible for the cost of treatment = this means YOU are responsible.

No the medical provider does not need to bill the insurance company before they bill you. Some medical providers NEVER bill the insurance company and make the insured (that's you) submit your own claims tot he insurance for medical treatment.

Did you re-submit the claims? It is probably past the claims submission period but it is worth a try.

The court is going to rule in the medical providers / collections agency favor. Whether you ignored the bills or not, it is still your responsibility to make sure they were paid and you didn't do this.

[tonibraxton]

If this was in 2007 and you're asking us now then I can only assume that you did drop the ball. You're the one that needs to stay on top of the office to make sure they're billing properly. If they don't and you ignore them, then that really falls in your lap.

That being said, you should really be checking with the PPO network as to their rules for billing. Yes, it is standard procedure for the doctor's office to bill the PPO network FIRST to get the bill repriced. Once it's repriced, they receive notice and you receive an EOB (Explanation Of Benefits)

[emek]

All that matters is if the insurance did not pay the doctor, you are liable for the entire bill. Every patient signs paperwork that you are financially responsible. Lawyers are not involved with Small Claims Court. Seems that you were not insured at the time of service. A doctor must bill a provider first to see what they will cover. Whatever is left uncovered is the patient's bill.

[aswynn81]

They will have a contract with that network. It's true that SOME networks, ONLY see patients IN THAT NETWORK, so ALWAYS have to bill the insurance company - that's the contract.

You've got several problems here:

1. This claim is 5 years old. It's been going on FOREVER.

2. You SHOULD have filed the claim yourself with your insurance company, to make SURE it got filed.

3. You should have receive "explanation of benefits" forms from your insurance company, directly, showing how much they covered, and what your share of the payment was. Your provider is claiming they received EOB statements - you will have to contact your insurer at the time, and ask for a copy.


If the provider doesn't have the correct information, or if they are not "in network" they do not have to bill the insurance company first. If you moved and they didn't have a correct address for you, they CAN'T get a bill to you - they have to use whatever address you told them.

Your ONLY chance of winning this is to get the old EOB's from your insurance company, YOURSELF, to show that the provider did or did not submit the bill; to get a statement from your insurance company that they were IN NETWORK and have a contract (which they may or may not have) that says if they don't bill the insurance within 6 months, they have to eat it and cannot bill the insured. And your EOB denial would state that.

If you cannot come up with an EOB that shows the claim was submitted, then you ARE going to lose that judgement, as you did sign that financial responsibility form.