Dear Consumer Ed:
A medical provider recently sent me a statement for $14,850.00, with charges dating from four to six years ago. The provider never submitted the bills to my insurance company as it had done in the past. The charges are far outside my insurance company’s contracted time (60 days) for consideration. Now the medical provider is threatening to send my account to a collection agency. Am I legally required to pay the full amount of these medical costs under these circumstances?
Consumer Ed says:
The answer depends, in part, on whether the provider was in-network or out-of-network and on whether you were an inpatient or outpatient.
If the doctor’s office is a participating or “in-network” provider through your insurance company, the doctor’s office may have violated the Georgia Fair Business Practices Act if either of the following scenarios occurred: 1) it failed to timely submit a claim to your insurance provider, resulting in the insurance company denying the claim and leaving you liable for the full amount; or 2) it told you it accepted your insurance but proceeded to charge you an amount that exceeded the contracted rate set forth by the insurance company. To verify this, you can contact your insurance provider. If you think the doctor’s office may have violated the law, you should submit a complaint to the Georgia Attorney General’s Consumer Protection Division by calling (404) 651-8600.
If your doctor is an “out-of-network” provider, it may be helpful to clarify whether your procedure was inpatient or outpatient. Your hospital status 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.
If you were an inpatient at a hospital, the facility has six business days after you have been released from its care as an inpatient to provide you with an itemized statement of all charges for which you are being billed. If the provider seeks charges from multiple years ago, it might have violated the law and you should submit a complaint to the Georgia Attorney General’s Consumer Protection Division.
If you were not an inpatient in a hospital, the law provides a statute of limitations which treats the bill like any other debt or payment owed for services. If you executed a written agreement to pay at the time of the appointment, the doctor’s office probably has up to six years from the date of the appointment to collect. If there was no written agreement, the doctor’s office may have up to four years to collect.
In the event that the statute of limitations has run, the debt attempted to be collected is time-barred (sometimes referred to as “zombie debt.”) While you may have a “moral obligation” to pay a time-barred debt that you legitimately owe, you do not have a legal obligation to pay it. IMPORTANT NOTE: You need to be careful not to restart the statute of limitations. Anytime you take an action with an account, the statute of limitations may be restarted. Making a payment, making a promise of payment, entering a payment agreement, or making a charge using the account may restart the statute of limitations on an account. When the clock restarts, it restarts at zero, no matter how much time had elapsed before the activity.
Submit your own question to Consumer Ed. Remember…we do not give legal advice. Always consult a lawyer about legal issues