MTBC was contracted to file claims on behalf of the provider who provided health care services on 8 February 15 February 22 February and 1 March. The claims submitted to the HMO and the subsequent bills I received were for $435.
According to the contract between the provider and the HMO I never should have been billed since there was no cost share or co-pay associated with the services rendered.in addition I should not have been billed since the HMO does not accept claims from patients. This is not my first experience with a medical billing service that chose to ignore the law and contractual agreements. As such I have come to the conclusion that the prevailing attitude by medical billing companies is to ignore the law and contracts using fear and intimidation as leverage to get paid regardless of whether the provider and medical billing service have filed the claim properly.
From June to November I received four billing statements. Each time I was told by MTBC and the HMO copies of the claims and EOBs are not provided to patients. MTBC customer service stated the account would be annotated and the HMO would be contacted.By November based on conversations with the HMO and MTBC I believed the problem had been resolved.
On 20 March I received a bill dated 14 Mar stating the $435 balance was over 120 days past due. The MTBC manager stated the HMO was waiting for information from the patient, the same response as when I first called in Jun. There was no record of any previous conversations I had with MTBC. Consequently I told the manager I wanted a letter stating I was not responsible for the bill and copies of the submitted claims forms for my daughter's care.
On 21 March I faxed MTBC explaining I would not pay the $435 bill and the HMO needed an updated W9 in order to pay the claims. On 26 March I was told Stephen Snyder, In House Counsel for MTBC, instructed MTBC customer service not to discuss the status of the account with me. On 27 March I faxed Mr. Snyder requesting MTBC refrain from sending me any further bills as MTBC as an agent of the provider was contractually prohibited from sending me any bills.
On 3 April Donald Wright, Accounts Manager for the HMO was gracious enough to send me copies of the Claim Denial Letters for claims MTBC submitted in behalf of the provider for services rendered to my daughter. On all of the claims denial letters it states, Provider on file does not match W9. Two of the claims indicate the claim was submitted after the billable period.
On 14 April I faxed Mr. Snyder a letter with the copies of claim denial letters and the email, dated 3 April from Mr Wright that indicated the provider directed MTBC to refrain from any further billing and that I was not responsible for the balance on the account. On 18 April I received another bill from MTBC for $435 and I emailed Mr. Snyder stating I considered the receipt of another bill from MTBC to be a clear violation of my rights under Public Law 95-109, Section 805-C.
On 19 April I forwarded the previously mentioned email to David Rosenblum, President of MTBC. I found it reprehensible that MTBC would send me bills but nobody from MTBC would discuss the account with me. On 21 April I received at letter from the provider stating I was not be billed, I was not responsible for payment, and no bills would be sent to any collections agencies. I also received an email and letter from Howard Resnick, MTBC CFO, stating the balance had been adjusted to reflect a zero balance.
Still patients should not have to be responsible for the failure of medical billing services to comply with HMO claims procedures. When providers or medical billing services do request the assistance of the patient to resolve a payment dispute with the HMO the patient should be entitled to receive copies of all claims in order to substantiate the assertion that the claims were submitted correctly and on time.
New Jersey HMO Law.
Pursuant to New Jersey law, an HMO must limit its members' liability for services rendered at an in-network hospital to the amount of the co-payment, deductible and/or coinsurance. See N.J.A.C. 11:22-5.6 (b). Likewise, an HMO cannot require a member to pay more than his or her co-payment, deductible and/or coinsurance with regard to emergency care rendered at non-participating hospitals. See N.J.A.C. 11:24-5.3 (b). Finally, a member cannot be obligated to pay any amount in excess of his or her co-payment, coinsurance and/or deductible obligation for services rendered by a non-participating provider if the HMO referred the member to said provider. See N.J.A.C. 11:24-5.1 (a).
Collectively, the above-referenced regulations provide that a member cannot be compelled to pay anything above-and-beyond the member's co-payment, coinsurance and/or deductible relative to care rendered by a participating provider or a non-participating provider if the member was referred to the provider by the HMO or the care constituted emergency services. With regard to such services, a payer must pay the non-participating provider's reasonable and customary fees. Balance billing is not permitted.
0 comments