If my insurance company misinformed my doctor that a test was covered at 100%, if it wasn’t am I liable for the payment?

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If my insurance company misinformed my doctor that a test was covered at 100%, if it wasn’t am I liable for the payment?

My doctor’s office informed me that my insurance company would cover my sleep studies at 100%. After having the test done twice (and being assured that the second would be covered as well), the office is billing me for the entire cost because the insurance company supposedly misinformed them. The office was aware I would not have the testing done unless covered. Do I have to pay the balance? It was their mistake.

Asked on July 29, 2010 under Bankruptcy Law, Georgia

Answers:

M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 11 years ago | Contributor

This is difficult to answer in a "yes" or "no" way.  I am sure that you medical provider had you sign a piece of paper that said that you would pay what your insurance company did not cover.  That is a pitfall for you but do not give up yet.  Did the medical provider get a pre-approval code or a reference number for the procedure(s)?  That is generally required.  And if they did then you have a fighting chance to have the no coverage determination re-reviewed (hopefully they took names and numbers).  If they do not have a reference number or pre-approval code (if they tell you it was not required) then they need to have a paper trail as to names and numbers they spoke with at the insurance company.  If you relied on them to pre-approve the procedure and they told you that it was covered then I would fight them tooth and nail.  They may sue you and you may have to pay something (a co-pay amount maybe) but do not give in at this stage.  Wait and see if they back down or "reduce" their fee.  Then re-asses the matter.  Good luck.


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