Suddenly, an EOB on a 3yo medical bill appears?

[galliver]

Long story short, I noticed today that an EOB (explanation of benefits) posted 3 weeks ago, or perhaps that's when the claim was processed, for a doctor's visit almost 3 years ago (March 2013). If I'm reading it right, it suggests I owe the clinic $300.

At the time, I was on a different plan with this company (grad student insurance at another school), and also on my parents' insurance, which I have since aged out of. The visit (and billing, I thought) was straightforward; I paid the amount asked for, checked the EOBs as they came in, had every reason to believe it was squared away. (I also had my wisdom teeth out at the same clinic about a year later and they didn't find any pending charges while checking my account related to that.) Anyway, since it all appeared fine, I doubt I kept the paperwork in physical form (esp since I moved), and I don't typically download local copies of electronically accessible docs, though it seems I should!

Has anyone had this happen or work in the field? Tips or advice on what to prepare/try to find, or how to talk to them?

I'm mad I have to deal with this. Grr.

[justajane]

This happened to us. I'm not sure it was even three years -- more like one -- and we called the insurance company. They were like "Oh, hell, no (not their exact words, but you get the picture), that violates their agreement with us. Don't pay it. We'll take care of it."

Anyway, it's worth a try to see if they insurance company will go to bat for you.

[galliver]

This happened to us. I'm not sure it was even three years -- more like one -- and we called the insurance company. They were like "Oh, hell, no (not their exact words, but you get the picture), that violates their agreement with us. Don't pay it. We'll take care of it."

Anyway, it's worth a try to see if they insurance company will go to bat for you.

Thanks!

[NoStacheOhio]

Most states also have a "failure to timely bill" rule with regard to medical expenses. I know for Ohio, if they can't bill properly within 12 months, they have to eat the charges.

[redcedar]

This happened to us. I'm not sure it was even three years -- more like one -- and we called the insurance company. They were like "Oh, hell, no (not their exact words, but you get the picture), that violates their agreement with us. Don't pay it. We'll take care of it."

Anyway, it's worth a try to see if they insurance company will go to bat for you.

+1 on this. You are the client of the insurance company. You are not really the client of the medical provider - the insurance company is their primary client. So this advice is spot on. You need to get the insurance company engaged on this.

[justajane]

I'm assuming your graduate school was the primary insurer and the parent's insurance was secondary? If so, I'd call the primary. I personally had a nightmare situation with primary and secondary insurance. As a grad student, my university forced me to be on their insurance and to make it primary, even though I was already married and my husband had much better insurance. Anyway, basically what it boiled down to was that in a few cases, both said they weren't going to pay because they thought it was the responsibility of the other. It was crazy. Essentially I had two forms of insurance and neither would pay.

It became such a pain that I decided to go half-time in the university system so that I wasn't obligated to get their insurance. It was fine, since I was at the end of writing my dissertation, but I couldn't avail myself of scholarships or TAships.

My only concern with your situation is that the primary insurance coverage was shitty (as if often the case with student insurance) and that might complicate things. And that you are no longer their client. Is it one of the big insurers at least?

[galliver]

I'm assuming your graduate school was the primary insurer and the parent's insurance was secondary? If so, I'd call the primary. I personally had a nightmare situation with primary and secondary insurance. As a grad student, my university forced me to be on their insurance and to make it primary, even though I was already married and my husband had much better insurance. Anyway, basically what it boiled down to was that in a few cases, both said they weren't going to pay because they thought it was the responsibility of the other. It was crazy. Essentially I had two forms of insurance and neither would pay.

It became such a pain that I decided to go half-time in the university system so that I wasn't obligated to get their insurance. It was fine, since I was at the end of writing my dissertation, but I couldn't avail myself of scholarships or TAships.

My only concern with your situation is that the primary insurance coverage was shitty (as if often the case with student insurance) and that might complicate things. And that you are no longer their client. Is it one of the big insurers at least?

I know the pain, somewhat. I think the cost to my dad to keep insurance on me was minimal when my sisters were already included (I believe I broached the subject once and that's what he said...?), and his insurance was definitely better so we kept it. But the few times I didn't go to the campus health center for care, the billing got complicated and they couldn't ever seem to do it right. I do remember on one occasion I finally got someone competent on the phone with one insurance co and they called up the clinic and the other company and sorted it out. I was on hold for like 30 min to an hour but had to exert no effort so I was grateful, heh. Both were(are) major companies...and I'm actually still a client with one just under a different plan/institution, which will hopefully make this smoother? Girl can hope. The quality of the plan/coverage has been adequate so far, but I've only really needed routine care the past few years, thank goodness.

It's ridiculous that they couldn't figure out who was supposed to be primary. From my research on the topic (back when I was using two) the secondary is supposed to cover up to their max whatever the primary doesn't...so you basically get the best of both worlds in terms of coverage. Rather than having them basically cancel out.

This happened to us. I'm not sure it was even three years -- more like one -- and we called the insurance company. They were like "Oh, hell, no (not their exact words, but you get the picture), that violates their agreement with us. Don't pay it. We'll take care of it."

Anyway, it's worth a try to see if they insurance company will go to bat for you.

+1 on this. You are the client of the insurance company. You are not really the client of the medical provider - the insurance company is their primary client. So this advice is spot on. You need to get the insurance company engaged on this.

Thanks (to you both)! I was actually going to call the clinic first but it sounds like that might be the wrong strategy to lead with. Glad I asked :)

[raven2963]

Humana has been doing some adjustments lately.  It may have been an automatic reprocessing of an old bill, when that happens and EOB generates.  Either way, I would call the clinic to make sure there isn't a balance.  If there is, then you can tell them to eat it.  You saw an EOB but you didn't get a bill.  You don't want something like this going on your credit.  Although I would seriously doubt it's at that point based on these "reprocessing" things that are going on.  Humana isn't the only one either.  Apparently some of these insurance companies found out (were threatened with a lawsuit) that they were processing certain claims incorrectly and are trying to make it right.  Hopefully this is the case here.

[Sibley]

Ok, there's a misunderstanding here. The EOB (explanation of benefits) is generated by the insurance company. Call them. If you need to call the provider, I'll be very surprised.

[galliver]

You saw an EOB but you didn't get a bill.  You don't want something like this going on your credit. 

Well, I moved over a year ago and I'm not sure the clinic has my new address (I had no reason to leave them one).

Ok, there's a misunderstanding here. The EOB (explanation of benefits) is generated by the insurance company. Call them. If you need to call the provider, I'll be very surprised.

The EOB is generated by the insurance company, but my concern was that the clinic was reprocessing something and ended up billing them.

[edit] I keep forgetting to call them because they're 2 hours behind and that's super inconvenient...

[Tom Bri]

I work claims in an insurance company, and believe me, this happens all the time, for several reasons. Most commonly, the provider forgot to bill, or the claim was somehow lost in transit and they forgot to follow up to see why we didn't pay. Unfortunately, we follow the 'one year timely filing' rule, so at that point you have to fight it out with the provider, unless there is a proper paper trail showing that they did TRY to bill.
I also see where sometimes we go back through the files and audit compliance, and once in a while an old claim will get uncovered and processed. This is very rare, but does happen, or the provider will come back after a few years and try to refight an old denied claim. Sometimes they win!
It also happens that medicare/medicaid will bill us years after the fact, so an old EOB might pop up, causing vast confusion to the insured, who can't understand why on earth we processed such an old claim.

Advice? Call the insurance company first, and find out why they are just now getting around to processing this claim. And, don't pay anything to the provider unless they actually send you a bill, even then, question them on why you owe this after so long. It may well be that this is a duplicate claim, and it was already paid 3 years ago.

As for the folks above complaining about primary and secondary coverage, I have fought this battle many times, and it sucks. There are so many variations, from divorce decrees, to effective dates, to group vs individual coverage, that getting it straight is a real chore. I have even had a few cases where we insisted we were primary, and paid in full, and so did the other company, so the provider got double paid, which is illegal. After months of trying to work it out, my top manager finally just had me tell the provider to refund the difference to the insured, since neither we nor the other insurance company was willing to take the money back! Still not right, but at least the provider's books wouldn't show an illegal balance if they got audited!

[galliver]

Finally remembered to call during THEIR workday!

Insurance told me they were adjusting for an overpayment and had to get a refund from the provider, which generated the EOB. Called the provider just to make sure and they verified there was no balance or other weirdness on my account. :) Much more straightforward situation than I feared!

Thanks everyone for your input/advice!