If a medical claim is denied because the provider did not file in time is the patient responsible for payment?

Answer

Check out this page where Medicare talks about providers being responsible for billing errors if it's their fault

http://www.cms.hhs.gov/manuals/13_int/a3700.asp

CA Civil Code # 3517. No one can take advantage of his own wrong.

3520. No one should suffer by the act of another.

3526. No man is responsible for that which no man can control.

3529. That which ought to have been done is to be regarded as done, in favor of him to whom, and against him from whom, performance is due.

3533. The law disregards trifles.

Answer

I would say no. I'm looking though for the documentation. Here's what I have so far....

Q52. How do my PPO benefits work?

A52. We have established a network of "Participating Providers". These providers are called "participating" because they have agreed to participate in our preferred provider organization program (PPO). . Receiving services from the Blue Cross PPO Provider network can substantially reduce your out-of-pocket costs. These lower costs are due to negotiated rates that Blue Cross PPO Providers have agreed to accept. These providers SHOULD file claims to Blue Cross for our members, then bill you for the remaining portion of their eligible charges. http://www.bluecrossca.com/pdf/faq/sg_member_faqs_ppo_plans_123002.pdf

For more info see www.SteveShorr.com

Answer

I checked with upper management at Blue Cross - here's their answer

Claims submitted by Participating providers after their contractual timely filing period are denied as a provider discount amount. The member is not responsible for these services.

There may be instances where a provider does bill the patient for this denial in error. When this occurs, the patient should either contact the provider and remind them this is a provider discount based on the EOB they received from Blue Cross or contact us directly and advise the provider is attempting to bill the member. In the later situation, we will then work with the provider to resolve the matter.

No the patient can not be responsible . It should be the providers writeoff.

First answer by Steve shorr. Last edit by Raamprathap. Contributor trust: 0 [recommend contributor]. Question popularity: 52 [recommend question]