Health Insurance Blame Game – Stuck Between Insurance Company and Doctor’s Office

Do you ever feel like navigating the health insurance claim process is like walking through a maze blindfolded?  Our most recent experience leaves me wondering how many people get stuck paying hundreds of dollars for claims that should have been covered.
During a recent visit to the pediatrician the receptionist informed my wife we had a balance of over $300 outstanding. Luckily she only paid the co-pay and got the phone number of the billing department so I could call and investigate.
Doctor’s Office Perspective


When I spoke with billing the next day, they informed me that the claim they had filed with our insurance company for a visit from December of last year had never been processed.  They started off by sending an electronic claim and after receiving no response they sent a follow up by either mail or fax.  When no response was received the doctor’s office then billed us directly.
Insurance Company’s Perspective


Having heard the pediatrician’s side of the story, I then called the insurance company to see what went wrong with the claim.  According to little miss phone rep the doctor’s office hadn’t submitted the necessary paperwork until April of this year, past the 90 day window stated in the contract between the doctor’s office and the insurance company.  According to the contract, since the pediatrician had waited too long to submit the claim, the insurance company was not liable for the charges and had sent the doctor’s office a letter informing them of this.
Patient’s Perspective
I pay my health insurance premiums monthly and a fork over a co-pay at every doctor’s visit; I’ve upheld my end of the contract.  I expect the insurance company and the doctor’s office to run their business correctly. I shouldn’t have to be stuck in the middle of the two parties trying to negotiate an agreement.