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I have been having problems with a healthcare provider and insurance company. The provider is in network. The insurance won't pay a portion of the bill because they said the provider hasn't sent the proper documentation. My EOB says we owe $0. The provider is billing us for this and it's significant and exorbitant for what it is. They said they sent what they're going to send to our insurance co and aren't dealing with the insurance anymore. Insurance tells me not to pay. We've called, sent letters, insurance rep has called and sent letters, and nobody from the doctor's office is talking to either of us anymore. They literally hung up on me last time and I promise I was polite. That was in Feb, but we've called and sent letters repeatedly since then and have not received any explanation in writing or any return calls. 

The insurance had their lawyers send a "balance bill" letter basically telling them they can't do this. I was to wait 30 days before the insurance would escalate it if I received more bills. I received 2 bills in the interim and finally after the 30 days passed we get something else. We expected they may try to send it to collections but they actually skipped that step and are suing me personally in civil court. They sent me a summons for August! I called the insurance co and they said to call back Monday and they'd try to talk to the provider again.

Has anyone dealt with this craziness? The bill is for something my insurance definitely would have covered if they received the proper documentation (cast for broken arm). Do I need to hire my own attorney or should I trust the insurance company to defend me? If I get my own attorney, it will be $$$- if I win, will the provider pay me back for those fees?

 

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talked to dh.

The dr HAS TO provide proper billing information to the insurance company.  they are contractually obligated to provide that information.  If they DO NOT provide proper billing information to an insurance provider to whom they are legally contracted - they don't get paid.    

if they fail and insurance company determines that the drs office did not provide proper information - you have no obligation to pay.  they can huff and puff, and you are not obligated to pay.

that is contract law between drs officers and insurance companies.  Your insurance company should be able to provide you with the contract between them and the dr's office - including their negotiated rate.  they CANNOT charge you more than the negotiated rate.  (they can try, but you're not legally obligated to pay it.)  I would also find out if they are truly active with that insurance company - or if the dr's office dropped them, but are advertising as being with them.  in which case, they're in breach of contract.  but get the copy of the contract between the dr's office and the insurance company.  it will give what the dr's office is obligated, what rates they can charge (generally a whole lot less than they charge out of pocket customers.), and what percentage you are legally obligated.  (after your insurance pays their part.)

 

2nd:

did they disclose ALL CHARGES *prior* to you receiving care?  if they don't - they cant' come in and charge you after the fact.

the dr's billing agent is a moron.

we had one who came after us two years after the fact - have no idea who they were, but their billing agent screwed them over. whatever it was, it was never submitted to our insurance company.  we sent them packing.

eta: dh said he'd be happy to point out all the legal terminology in the contact that demonstrate the dr is legally obligated to submit correct billing information to the insurance company if they want to be paid.

Edited by gardenmom5
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Go to your insurance commisioner's website right now and file a complaint. (state office). What they are doing is illegal, and nothing solves this stuff faster than the insurance commisioner's office looking into it. I've had to do it myself, as have friends, and it has always worked. 

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One thing- I did sign something saying that I'd pay what the insurance doesn't cover- can they use this against me? Insurance co says no. I agree and feel like I can't sign something that says the provider can violate their contract with another party, but it worries me. This bill is not for something non covered- it would be covered if the insurance receives the info they want. 

I think it's too late to resolve this amicably- if I personally do not show up at a court hearing I accept the debt. So I must show up, but I'm not sure if I need to be calling my own attorney asap. 

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9 minutes ago, Ktgrok said:

Go to your insurance commisioner's website right now and file a complaint. (state office). What they are doing is illegal, and nothing solves this stuff faster than the insurance commisioner's office looking into it. I've had to do it myself, as have friends, and it has always worked. 

I just went to the website and it looks like it's for complaints against insurance companies, not medical providers. 🤷‍♀️

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26 minutes ago, Ktgrok said:

Go to your insurance commisioner's website right now and file a complaint. (state office). What they are doing is illegal, and nothing solves this stuff faster than the insurance commisioner's office looking into it. I've had to do it myself, as have friends, and it has always worked. 

truth.  the insurance commissioners office should strike fear in a dr's office over insurance matters as well an insurance company.

eta: BBB, there should be somewhere.  dept of licensing - that dr is licensed with the state.

Edited by gardenmom5
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I recently went through something like this that had dragged on for almost a year!  I finally sat down and wrote a letter explaining everything, put all of our necessary info in it, and addressed it to everyone involved:  including, the health facility, the president of the health facility, the insurance office, the president of the insurance office, also in your case the attorney now involved, etc.  I presented all the information and basically told them to figure it out amongst themselves and with each other -- they're the experts, and I know I don't owe anything.  Once I involved everyone on the same letter, they finally got to work and called each other and settled it.  Saved us about $30,000.

ETA:  In the end, it was the health facility who was at fault because of improper billing.

Edited by J-rap
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I believe I would speak with someone higher up in the insurance company as well.

We're in the middle of something similar, and it sounds like the same process has happened with us, BUT when the provider and collection agency contacted me *after* receiving the balance bill letter (which informed them that they are now dealing with the lawyers and not me) I notified insurance and their lawyers took care of it. I haven't heard from them again. (Ours is different in that the provider doesn't need to provide anything; it's a bill that was audited by insurance and adjusted, and the provider is billing the patient for the adjustment.)

So while it sounds like your insurance has started the process, it doesn't sound like they're following through in a timely manner. I have no idea as to any legal obligation the insurance company actually has. But it seems like usually they have some kind of dept to do things like this. I'd try to talk to someone in that dept who can move things along, if possible.

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12 hours ago, J-rap said:

I recently went through something like this that had dragged on for almost a year!  I finally sat down and wrote a letter explaining everything, put all of our necessary info in it, and addressed it to everyone involved:  including, the health facility, the president of the health facility, the insurance office, the president of the insurance office, also in your case the attorney now involved, etc.  I presented all the information and basically told them to figure it out amongst themselves and with each other -- they're the experts, and I know I don't owe anything.  Once I involved everyone on the same letter, they finally got to work and called each other and settled it.  Saved us about $30,000.

ETA:  In the end, it was the health facility who was at fault because of improper billing.

I’m hesitant to send anything in writing myself now because it may be used against me. I think I should get my own attorney and have him send a letter and then sue for attorney fees. 
 

It’s interesting to me that my name is on the warrant while DH’s name is not but has been the one on all of the bills. My name has never been on a bill. I sent the previous letters that included a copy of our EOB saying we owed $0. I don’t even think I was present when she got the brace they are suing for.
 

It also looks like our state law says that nothing I sign can override the hold harmless clause that is required for all state approved insurance/provider in network contracts. 
 

It seems that what they are doing is really illegal- so why are they so confident and unresponsive? It makes me nervous. 

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6 hours ago, Paige said:


It seems that what they are doing is really illegal- so why are they so confident and unresponsive? It makes me nervous. 

Because a lot of people would just pay up to avoid going to court.

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21 hours ago, Paige said:

One thing- I did sign something saying that I'd pay what the insurance doesn't cover- can they use this against me? Insurance co says no. I agree and feel like I can't sign something that says the provider can violate their contract with another party, but it worries me. This bill is not for something non covered- it would be covered if the insurance receives the info they want. 

I think it's too late to resolve this amicably- if I personally do not show up at a court hearing I accept the debt. So I must show up, but I'm not sure if I need to be calling my own attorney asap. 

 

I don't think it's legal for them to have asked you to sign something like that. In my state, if a provider is contracted in-network with an insurance company, they agree to the insurance company's rate for the service and we cannot charge more than that. So, for a therapy appt, we could ask the insurance company for $1000/appt, but they'll only pay about 1/20th of it and we are contractually obligated to accept it as payment in full.

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Posted (edited)
13 minutes ago, AmandaVT said:

 

I don't think it's legal for them to have asked you to sign something like that. In my state, if a provider is contracted in-network with an insurance company, they agree to the insurance company's rate for the service and we cannot charge more than that. So, for a therapy appt, we could ask the insurance company for $1000/appt, but they'll only pay about 1/20th of it and we are contractually obligated to accept it as payment in full.

I think you are correct. When I signed, I assumed it meant I would pay for things that weren't covered, which I would. They are telling me that the claim was denied, but the insurance is telling me that the claim was not denied but that the provider did not submit it properly. The insurance company has called them and told them they can't do this and explained what they need to do in order to be paid, but the provider's billing office is "refusing to deal with this anymore." They also lied to me repeatedly. They said they billed my secondary insurance but they did not on multiple occasions. Secondary insurance said they had received no claims each time I called to recheck after they said they were sending it "this time." This week, right before the debt warrant arrived, we were surprised to finally see an EOB from our secondary insurance but they denied everything because it was submitted too late. The date of service was 2/2019. They are also in network for our secondary insurance. 

It's ridiculous- everyone knows that if a kid breaks a bone some sort of brace or cast is required- that's what isn't being processed. The x-rays, visits, and all the rest were covered. 

I'm jaded after a negative experience with the school, however. I don't think people care about the law unless you force them to with your own attorney. 

Edited by Paige
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21 hours ago, gardenmom5 said:

truth.  the insurance commissioners office should strike fear in a dr's office over insurance matters as well an insurance company.

eta: BBB, there should be somewhere.  dept of licensing - that dr is licensed with the state.

I looked up our state's licensing complaints form and it specifically says they don't address complaints related to billing practices. I'm going to call the insurance commissioner's complaint help line on Monday after I talk to our insurance co. again. It looks like they are the right place, but the standard form doesn't have an option that looks correct to me. 

Good news is we looked up the attorney they hired to go after us and it looks like he's terrible. He's had multiple complaints and sanctions and this isn't even his area of specialty.

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1 hour ago, Paige said:

I looked up our state's licensing complaints form and it specifically says they don't address complaints related to billing practices. I'm going to call the insurance commissioner's complaint help line on Monday after I talk to our insurance co. again. It looks like they are the right place, but the standard form doesn't have an option that looks correct to me. 

Good news is we looked up the attorney they hired to go after us and it looks like he's terrible. He's had multiple complaints and sanctions and this isn't even his area of specialty.

he's probably the only one they could get to take their case.

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9 hours ago, Paige said:


 

It seems that what they are doing is really illegal- so why are they so confident and unresponsive? It makes me nervous. 

Because whomever is doing the billing is stupid. 

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The person doing the billing is probably making less than $15 an hour and doesn't know what they are doing.  Similar, though slightly higher pay for the entry level customer service reps at the insurance company.  They don't have either the knowledge or authority to make any decisions, but they are a sort of gatekeeper for keeping the stress away from the people who can solve these problems.  You need to use the words to get past the gatekeepers.

First call the doctor, ask for the doctor themselves or the office manager.  Tell them what has happened and that after this call you will be calling your attorney, and you plan on countersuing the physician for all legal costs.  Then call the insurance company and using the words "Insurance commissioner" and "lawyer" with the insurance company will ensure that it will get escalatd BOTH to upper management immediately, and likely the insurance company's legal department. 

Then DO file a complaint on your insurance commissioner's website.  Even if the insurance company isn't at fault, it isn't your problem that they haven't managed to communicate how to properly file a bill with the provider.  That IS their problem, not yours.  Especially if 5 other people provide similar complaints about the same company that week and the insurance commissioner can see the pattern that you cannot and launches into an investigation into them that can cost them fines, and if a pattern of fraud is found, much more.

It's amazing how threats of upper management and government bureaucrats can make these "problems" that people typically ignore rise right to the top of the priority list.

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In our situation, and which I left out when I explained above (I actually forgot about it till now), was that I did find someone personally in each place -- one person within the medical facility and one person at the insurance company, who felt sorry for me and agreed to be a contact person for me.  That helped a lot!  And at one point, one of those people actually helped arrange a conference call with someone from the health facility, someone from the insurance company, and me.  It STILL didn't solve it (they still both blamed each other which in the end meant I would have to pay!!).  But, that did mark the beginning of the end, which turned out in my favor.  (Which I really expected.)  In your situation, I'd expect the health facility to be at fault.  There are lots of health care billing situations that can be a little tricky.  A health insurance company probably knows about all of them, but a health facility might not, and not report/code properly.   Our of curiosity, do you have a secondary health insurance involved?  Or Medicare?  

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We have a secondary insurance but not Medicare. They didn’t bill them at all until it was past the filing deadline. I think they must have mislead my secondary payer too because the EOB from them looks fishy. 

I have talked to the office manager. She’s the one who hung up on me and said they weren’t resubmitting anything. And she hasn’t returned any of our calls since then.

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On 6/19/2020 at 8:57 PM, gardenmom5 said:

truth.  the insurance commissioners office should strike fear in a dr's office over insurance matters as well an insurance company.

eta: BBB, there should be somewhere.  dept of licensing - that dr is licensed with the state.

The insurance commissioner’s office told me they will take a complaint and investigate to see if my insurance company has been processing things correctly on their side but that they have no authority to sanction or investigate the provider. 
 

I’ll file the complaint in case it helps motivate them to come down harder on my provider. I’m having a hard time finding an attorney to talk to, however. They don’t like to do anything that involves medical bills. I’ll call more people tomorrow.

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2 hours ago, Paige said:

The insurance commissioner’s office told me they will take a complaint and investigate to see if my insurance company has been processing things correctly on their side but that they have no authority to sanction or investigate the provider. 
 

I’ll file the complaint in case it helps motivate them to come down harder on my provider. I’m having a hard time finding an attorney to talk to, however. They don’t like to do anything that involves medical bills. I’ll call more people tomorrow.

it's the way the laws are written.  the AMA has a very big lobbyist group that pushes for laws to protect drs - even incompetent ones.

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34 minutes ago, itsheresomewhere said:

Besides doing up-  call your insurance company and ask to file a provider complaint with them.  They usually have someone who does this and in my experience, they were very good to deal with.  

Great idea!

I've complained to the licensing board and to the insurance commissioner. I don't know if anything will come of either one. I kind of feel bad complaining about the doctor who was a nice guy. But it's his responsibility if he lets people bill for him. 

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21 minutes ago, Paige said:

Great idea!

I've complained to the licensing board and to the insurance commissioner. I don't know if anything will come of either one. I kind of feel bad complaining about the doctor who was a nice guy. But it's his responsibility if he lets people bill for him. 

That's probably a good idea...  I remember for another situation we had, that it was the doctor who decided how to bill the event which evolved into a lot of expense for us.  And it could have (and should have) been billed differently, not just to save us money, but common-sense related!  

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  • 3 weeks later...

Update-

So far nothing much has happened except I got another warrant posted on my front door this week. Our state insurance commissioner said since the policy was from another state (we didn't know that- it's employer based) they had to send the complaint to the state it was licensed in. I haven't heard boo from that state.

Our primary insurance escalated the issue and said they'd call me within 10 days. No call. I called at about 12 days out and they said they'd talked to some people and were supposed to get a call back like a week before and never received the call from the billing office. They said they'd follow up but I haven't heard from them in 4 days.

Our secondary coverage is Tricare which gives us a lot of legal protections. However, they are just as messed up! Tricare improperly processed the claim and we don't know why. There's an advocate working with me to expedite things but so far it hasn't been reprocessed. She contacted the doctor's billing office too and they acted like they had NO IDEA there was an issue. 🙄She's waiting for them to get back to her too after they check into it. (fat chance)

Nobody can assure me it will be settled before the court date at this point. Do you all think it would be ok or a really bad idea to contact the opposing attorney and let him know how screwed up his case is in the hopes he'll persuade them to drop it before they get hit with a bunch of fines? Or maybe send a personal letter to the doctor involved? We don't have an attorney yet because we are hoping to avoid the expense because getting attorney fees recovered is not guaranteed. I think we'll have to get an attorney within a week or two if the insurance companies haven't worked things out so that we'll have time to prepare. With Tricare as secondary the doctor's office is really putting themselves in jeopardy with this but I don't want to try to explain this to the judge pro se.

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Boo!  I'm sorry it hasn't resolved.  Out of curiosity, did you ever find out what exactly the proper documentation is that your insurance company is requesting?  Can you get them (the insurance company) to put it in writing?  Then, send a professional-sounding letter to your health provider with that exact request, and cc it to the insurance company.  Heck, maybe cc it to a government official!  

Okay, I just looked up who (in government) you'd complain to about something like this, and in our state, it's the Office of Attorney General.  So another thing you can do is write to the Attorney General's Office (or whatever office it would be in your state), and cc both your health provider and insurance company.  Briefly explain the situation, how it has evolved, and why you believe you are being incorrectly billed.  Specify the documentation your insurance company is waiting on that the health provider has not sent.  Ugh.  That kind of staff makes me so mad!  They should be figuring this out themselves, not making you do the leg work! 

 

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At this point, I agree that you need to ask the insurance company exactly what info it was they didn't get. Then get a copy of that info yourself from the doctor, and send it to the insurance company. 

and I'd be considering social media

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You got a document that says warrant?  Not summons or something like that?

It's time to get an attorney involved.  And possibly local news.  But definitely an attorney.

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The insurance company wants doctors’ notes justifying the brace for her broken arm. They probably actually sent it already, but insurance says they didn’t submit it the proper way. They just resubmitted what looks like a duplicate claim rather than submitting an update to the original claim or something. I’ve already sent them a letter saying exactly what they need to fax. 

The billing office claims that they never received the official balance bill letter from the insurance co. That’s a lame excuse b/c “network management” from the insurance co followed up personally and gave me names and dates.

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4 minutes ago, Katy said:

You got a document that says warrant?  Not summons or something like that?

It's time to get an attorney involved.  And possibly local news.  But definitely an attorney.

It’s a warrant in debt which is a civil suit- taped on my door by a sheriff. Court date is in about a month. I’m afraid attorney fees will equal or exceed the bill. 


I’ll try an attorney general complaint. I’m really wondering how many other people they have harassed who just paid up.
 

I don’t know if DH has talked to anyone at work. I’m so uncomfortable with getting media involved. I like to stay quiet and anonymous. 

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Ok, htat's ridiculous. Are they trying to say that a broken arm might NOT need a brace? I'm back to saying the insurance company is the problem, not the doctor's office. Definitely follow up on the insurance commisioner thing, maybe go to the state website for the state they are based in and make a claim directly?

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(hugs)

So much stubbornness!!  "Submit the right paperwork and get paid without going to court!". "pay the claim without the perfect paperwork and avoid the cost of going to court!". But it seems they'd rather go to court than do some paperwork.  Ugh.

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3 minutes ago, Ktgrok said:

Ok, htat's ridiculous. Are they trying to say that a broken arm might NOT need a brace? 

Right? It’s all so ridiculous. 
 

The insurance said many times that they’re still happy to process the claim. But since they’re in network, whatever their dispute is shouldn’t be my problem to sort out. 
 

It could be that the office is balking because the doctor didn’t write sufficient notes? I don’t know. Maybe a plaster cast is cheaper but the doctor didn’t document that DD had serious eczema on the area? I saw the notes myself and didn’t see anything about why the brace was chosen.

I’m also angry because during a pandemic they’re trying to force me, a person with poorly controlled asthma, to spend hours at the courthouse if I don’t want A judgement against me. They don’t know I have asthma but it could be anything.

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24 minutes ago, Jean in Newcastle said:

Any communication with them should be sent certified mail with a signature required to prove that it didn’t get “lost in the mail”. 

I’ll ask the insurance company if they have proof of receipt for the letter they claim wasn’t received. I received a courtesy copy.

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This reminds me so much of whenever I have a problem with my internet, and the internet company says our phone line/phone company is to blame, and vice versa.  Just talk about it with each, people, and figure it out!!  It's almost always a very simple problem -- and never should be my problem.

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If you have to show up at court it is time to make sure your DH calls his HR department and makes sure the benefits coordinator understands you're getting sued because your insurance company won't pay the contracted rate of the in network doctor.

This is the reason benefits coordinators make more than $100k.  To be in charge of straightening crap like this out or to find the company a different insurance provider who will make sure this won't happen.   I get that it's uncomfortable to make a scene but this is the time a scene is called for.  When you're talking a dollar amount that it's more worth it to the health care provider to sue than to sell the debt to a collections company you need a scene.  And potentially a lawyer.  Someone's committing fraud and it isn't you.

ETA:  File a complaint with the insurance commissioner in the right state.  Clearly that got somewhere, even if the answer was "Not our jurisdiction."

Edited by Katy
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I talked to my insurance co today and they said last Thursday, the provider told them they had spoken with me on Weds (the day before) and informed me that the court date was cancelled. :blink:. They haven't called me since Feb and there's nothing from them on my caller ID. I haven't changed my number. 

They are also claiming I owe a copay which the insurance rep just accepted. But no, when I told him to check they verified I did not owe anything else, so they'll be calling them back.

I think it's probably settled now but I'm not going to be comfortable until I see it in writing. The insurance rep said they'd make sure I get that, but we'll see. 

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On 7/10/2020 at 10:36 AM, Paige said:

Do you all think it would be ok or a really bad idea to contact the opposing attorney and let him know how screwed up his case is in the hopes he'll persuade them to drop it before they get hit with a bunch of fines? Or maybe send a personal letter to the doctor involved? We don't have an attorney yet because we are hoping to avoid the expense because getting attorney fees recovered is not guaranteed. I think we'll have to get an attorney within a week or two if the insurance companies haven't worked things out so that we'll have time to prepare. With Tricare as secondary the doctor's office is really putting themselves in jeopardy with this but I don't want to try to explain this to the judge pro se.

DO NOT CONTACT THE OPPOSING ATTORNEY FOR ANY REASON. 

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On 7/13/2020 at 11:11 AM, Paige said:

I talked to my insurance co today and they said last Thursday, the provider told them they had spoken with me on Weds (the day before) and informed me that the court date was cancelled. :blink:. They haven't called me since Feb and there's nothing from them on my caller ID. I haven't changed my number. 

They are also claiming I owe a copay which the insurance rep just accepted. But no, when I told him to check they verified I did not owe anything else, so they'll be calling them back.

I think it's probably settled now but I'm not going to be comfortable until I see it in writing. The insurance rep said they'd make sure I get that, but we'll see. 

I agree with previous posters. Don"t trust that the court date is cancelled. Don't talk to opposing attorneys. They are definitely not your allies!  File an insurance complaint in the correct state.  Notify your husband's HR that this is happening. 

When you speak to them, do they tell you the call is being recorded?  You can also ask for a call reference number and the name of the representative.  Take notes of what is said during each call and note the date in case the recording needs to be referenced. Keep a record of contacts with all parties.  Hugs to you.

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I called the court today because I hadn’t received anything in writing. Guess what? Court date was NOT cancelled! 
 

Called insurance co, they put me on a conference call, and the provider said it wasn’t cancelled because it was my job to do it! I said that sounded ridiculous but she held firm and gave me a number for the collections agency (that I didn’t have before because I never received a collections letter). 
 

I called the collections agency and said that this is going to sound crazy but the provider told me to call them and tell them to call it off. They laughed and said, no offense but we would never do that! They put me on hold forever, called the same person I was talking to before, came back, and said they’d send me a dismissal letter today. 
 

Who knows if I’ll get it. Hopefully this is the end. I’m going to file a provider complaint next. 

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  • 2 months later...

Update:

We just got another bill from them. What on earth? They never stop. 

ETA: We did get a dismissal letter in July or August

Edited by Paige
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