Linda Brandwin, R.N. Linda Brandwin is a registered nurse and a medical billing and claims specialist. For the past 10 years she has worked directly with insurance companies to give advice and guidance to the health care consumer. Readers may send email or write Linda Brandwin at 5500 Single Oak Hill Ct., Woodbridge, VA 22192.

Hospitals responsible for sending claims to insurance companies
April 30, 2004

Q: About a month after my mammogram, I received a notice from my insurance company that they paid a radiology group for the mammogram that was performed at my local hospital. I assumed that was the only bill involved for my visit. One year later, I was very surprised to receive a letter from the hospital indicating that I had an outstanding balance.

Upon receiving this notice of an overdue bill, I called the processing center of the hospital. A woman told me she would check into the matter and call me back within a few days. I did not get her name. A week later when I still had not heard anything, I called again. A different woman, ( I did get her name,) told me she saw in the records where I had called last week but they had no time to follow up with my insurance carrier regarding this claim. She suggested that I take the matter up with the insurance company directly. I told her that I felt it was the responsibility of the hospital to work the matter out with the insurance company as this was a covered expense. I have not seen an explanation of benefits from my insurance company regarding this particular bill, so I wonder if the insurance company even received this claim.

Now about three weeks later, I still have not heard anything from the processing center. I am concerned that if I do not pay the bill, the hospital will turn the matter over to a collection agency. Since the bill is over a year old, I am sure it will be difficult for me to get it paid by the insurance company. Do you have any suggestions?

A: I am guessing that there are two different claims for your mammogram. One is for the radiology group that read and interpreted the mammogram; the other one is for the hospital that actually performed the procedure. The radiology group was paid, the hospital was not. If the hospital is a provider with your insurance company, it is the responsibility of the hospital to send the claim to your insurance company. This is part of the hospital's contract with your insurance carrier. The hospital needs to follow up on this matter with your insurance company and resubmit the claim if necessary.

However, it would be a good idea for you to call the insurance company yourself, and find out the status of this claim. Find out if the insurance company received the claim, if it was processed, if the insurance company paid, and if you owe anything. Also, you will have to call the processing center of the hospital again. It is far better to know what is going on, than to just wait and see what happens. This way, at least you have some control over the matter. The difference with this phone call will be that you are armed with all of the necessary information. Ask the processing center what kind of follow-up they have done regarding this claim. If their answer conflicts with the insurance company information you just received, the center will have to resolve this issue.

If this bill is over a year old and the insurance company has never received this claim, it is possible that the insurance company may not be obligated to pay it. However, neither will you. The hospital has a responsibility to submit claims in a timely fashion. They also should keep track of outstanding claims before they become a year old. If the hospital continues to bill you, and you are concerned about being sent to collections, call your insurance company. They will be able to offer you the necessary information and guidance to resolve this problem.