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

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:

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