Is your medical provider refusing to submit your bills to your health insurance company?

At Abrenio Law, we always advise our Virginia car accident victims to use their health insurance for their medical treatment.  By doing so, they have access to care, maximize their chances of recovery, and doing so helps avoid their bills going to collections.  But we also advise our clients to make sure to follow up.

Providers don’t always do what they are told.

Over our years of practice, we’ve encountered many clients who inform us that they notified their medical providers of their health insurance, provided their information, only to learn later that the bills were not actually submitted. Perhaps they learn from a collections notice or a call from the billing department.  Sometimes, it’s us who inform the client of the outstanding bill.

Given that, we believe you should be proactive.  Review your bills when you receive them to make sure insurance paid.  If there’s something unclear, call the provider and specifically ask the status.  If they tell you that it’s the insurance company’s fault, call your insurer to investigate why a bill hasn’t been paid.

Providers get more money if you pay out of pocket.

While sometimes bills not being submitted by the providers is not malicious (things happen), remember that the provider has a financial incentive for you to pay the bill out of pocket rather than being paid by the health insurance company.  For “In-Network” providers, they are typically only paid the “negotiated rate” by the insurer (and perhaps a co-pay by you).  But ordinarily this will be less money that if you simply paid the bill out of your own pocket.  So, providers have an inherent incentive to be paid out of pocket.

In-Network Providers have a legal duty to use your health insurance.

Did you know that Under Virginia Code Section 8.01-27.5, your medical provider (assuming they are in-network to your health insurer) is required to submit your bills to your health insurer by law?  Further, under subsection (B), if they fail to do so, they won’t get paid:

If an in-network provider does not submit its claim to the health insurer in accordance with the requirements of this subsection, then (i) the covered patient shall have no obligation to pay for health care services for which the in-network provider was required to submit its claim, (ii) the in-network provider shall not have the benefit of the liens provided by §§ 8.01-66.2 and 8.01-66.9 with regard to health care services for which the in-network provider was required to submit its claim, and (iii) the in-network provider shall be prohibited from recovering payment for any of the health care services for which it was required to submit its claim from an insurer providing medical expense benefits to the covered patient under a policy of motor vehicle liability insurance pursuant to § 38.2-2201, by exercising an assignment of the covered patient’s rights to the medical expense benefits or by other means. 

Virginia Code Section 8.01-27.5 (B)

So, if you’re In-Network Provider is refusing to use your health insurance, send them a copy of 8.01-27.5, and remind them of their duties.  If they refuse to comply, they aren’t getting paid.

Still have questions?

Make sure to check out our Personal Injury & Criminal Defense Practice Pages where we’ve answered many other questions you likely have.  James Abrenio is a Fairfax-Based Personal Injury & Criminal Defense attorney who practices throughout Northern Virginia. You can learn more about James Abrenio, some of our Prior Results, and Read Our Reviews.  Make sure to contact us at Ph. 703-570-4180 for your Free Consultation.