How long does a hospital have to bill a patient for an out-patient procedure?

March 10, 2015 16:07 by Consumer Ed

Dear Consumer Ed:

How long does a hospital have to send me a bill for an out-patient procedure?  It has been four months since the procedure, and it is hard to know how to budget for this expense. In addition, it may be too late by the time I get the bill to claim it as part of my medical expenses on my taxes.

Consumer Ed says: 

First of all, it may be helpful to make sure you are actually an outpatient.  Your hospital status, i.e. whether the hospital considers you an “inpatient” or “outpatient,” affects how much you pay for hospital services (like X-rays, drugs, and lab tests).  For example,

  • You are an inpatient when you are formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.
  • You are an outpatient if you are getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital.


Your hospital status also affects whether the law clearly mandates a timeline for hospitals to provide you with a bill.  If you were an inpatient, Georgia’s Fair Business Practices Act requires a hospital or long-term care facility to provide you an itemized statement of all charges for which you are being billed within six business days after you have been released from its care. It does not contain a similar deadline for hospitals to issue a bill for outpatient services or procedures.  However, there are several steps you can take to speed up the process.

First, you should contact the hospital’s billing department and inquire into the status of your bill. Hospitals generally have specific billing timelines, and processes to follow. The Georgia Administrative Code mandates that hospitals should develop, implement and enforce policies and procedures to ensure that each patient is provided an itemized statement of all charges for which the patient is being billed.  Hospitals are also required to provide, upon your request, a written summary of hospital charge rates per service to allow the patients to assess the charges and make cost effective decisions in the purchase of hospital services.  The American Hospital Association issued similar guidelines to encourage hospitals to respond promptly to patients’ questions about their bills and to use a clear and patient-friendly billing process.

Under Georgia law, patients have the right to inquire as to the estimated charges for a routine office visit, routine treatments, and lab tests prior to receiving such treatment.  It’s still the patient’s responsibility to determine the insurance coverage, but you can always ask the hospital about the costs associated with routine office visits, routine treatments, and lab tests.

There may also be a timely filing requirement for hospitals, depending on what type of medical insurance plan you have:

  • If you have Medicare, the Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided.
  • If you have Medicaid, the provider must file the claim three months following the month the service is provided.  If you have Medicaid and a third-party insurance plan, in general, your provider will bill the third-party insurance plan first, and then to Medicaid for consideration of payment not to exceed the sum of the deductible, copayment, and coinsurance.  If you have Medicaid and a third-party insurance plan, effective July 1, 2011, Medicaid must receive the claim after the third-party insurance, but within 12 months of the date of the month of service.
  • If you have private health insurance, the insurance company may only accept claims submitted by health care professionals within a specific period of time.  For example, Cigna only considers in-network claims submitted within 3 months after the date of service.  This timeline may be longer if the treating physician is out-of-network.  You should read your insurance company’s Explanation of Benefits (EOB) to see if it has a similar timely filing requirement. You can also contact your insurance company to find out whether your hospital has already provided it with your medical bills.

Additional questions about this? Here’s who to contact:

  • What is covered by my insurance?   
    Contact the insurance company directly. For Medicare, go to www.Medicare.gov. For Medicaid, visit www.Medicaid.gov.
  • Claiming tax exemptions for medical expenses
    Contact the IRS - www.irs.gov
  • A Georgia hospital did not provide an itemized statement of the charges you are being billed for.
    Contact the Georgia Department of Community Health - www.dch.georgia.gov
  • A Georgia hospital or long-term care facility did not provide a detailed bill for in-patient hospital stay within 6 business days.
    Contact the Georgia Department of Law’s Consumer Protection Unit – www.consumer.ga.gov
  • Filing a complaint against a health insurance provider   
    Contact the Office of Insurance and Safety Fire Commissioner - www.oci.ga.gov

 

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Can a collection agency add fees on to a debt?

March 7, 2013 22:55 by Consumer Ed

Dear Consumer Ed:

I'm in grad school and had some medical care that I was told was covered by my insurance. The insurance company wouldn't pay and now the doctors say that it's been turned over to a collection agency and there's an additional 38% fee. That's another $400. Is that legal?      

Consumer Ed says: 

If a bill goes unpaid, it is common for the original party to sell the debt to a third-party collection agency after a reasonable period of time.  Your doctors are legally permitted to turn over your debt to a collection agency without giving you any notice.  Turning debts over to collection agencies enables the original party to focus on their business instead of chasing their delinquent clients or customers. 

What might be illegal is the 38% fee that the agency added onto your debt.  Debt collectors can add reasonable charges to your debt, but only if you agreed to pay collection costs in your original contract with your doctors.  To determine whether these fees are reasonable, you will need to know why you are being charged the additional 38% fee.  You are entitled to an explanation of this fee from the collection agency.  Some examples of reasonable charges are for attorney fees, court costs and legal fees as allowed by state law.

Debt collection is regulated by the Federal Fair Debt Collection Practices Act (FDCPA).  If the collection agency is trying to collect unreasonable fees or fees to which you never agreed, they are in violation of that Act.  In that case, you have the right to sue them through a private attorney in state or federal court within one year from the date of the violation.  If you win, you may recover damages in the amount of any losses you suffered as a result of the violation, plus an additional amount of up to $1,000.00.  You may also be able to recover court costs and attorney fees.  However, please remember, even if the debt collector violates the FDCPA, that does not erase the legitimate debt that you owe.

If the collection agency has violated the FDCPA, you may also file a complaint with the Georgia Department of Law’s Consumer Protection Unit, provided that the debt collector is not an attorney licensed in this State.  You can contact the Georgia Department of Law’s Consumer Protection Unit at www.consumer.ga.gov  or by calling 404-651-8600 or 1-800-869-1123 (toll-free in Georgia, outside of the metro Atlanta calling area).  You should also file a complaint with the FTC.  You can contact the FTC at www.ftc.gov or by calling 877-FTC-HELP.  If the debt collector is an attorney, you should contact the State Bar of Georgia at www.gabar.org or by calling 404-527-8700.

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Is it legal for auto body shop to pay insurance deductible?

December 6, 2011 20:35 by Consumer Ed

Dear Consumer Ed:

I wrecked my car and it needs major body work. I saw an advertisement for an auto body shop that said they would pay my insurance deductible.  Is that legal?

Consumer Ed says: 

While having the auto body shop pay for your insurance deductible might not be illegal at face value, we would strongly caution you against it.  First, you should look carefully at the specific terms of the contract you have with your insurance provider.  Allowing the auto body shop to pay the insurance deductible may violate the terms of your policy (frequently, insurance contracts state that the policy holder must pay the deductible).  Also, it is likely that the auto body shop will want to recoup the extra cost of the deductible somehow.  It can do this in one of two ways:  by charging the insurance company more than what the repairs would actually cost, which would constitute insurance fraud; or, by spending less money and time on repairing your car, which could lead to more problems in the future (as well as a depreciation of the value of your car). Or, it could do a combination of both of these things. The fact that a practice may not technically be illegal doesn’t make it a good idea, especially if it’s an offer that seems too good to be true!

For more information, you should contact Georgia’s Office of Insurance and Safety Fire Commissioner by visiting www.gainsurance.org, or by calling 800-656-2298.

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