The hospital failed to submit a bill to my health insurance company within the one-year filing limit. Can I be held liable for the bill because they failed to file?

J.L.

What is one of the first questions you have to answer when you visit your doctor, enter an emergency room, or are admitted to the hospital? You're always asked what insurance you have. In fact, not only do you fill out a form specifying the name and address of your insurance carrier, your policy or group number, your personal identification number, and any other pertinent information about your insurance, but you may also be asked to sign an "assignment of benefits" form, where you authorize the provider -- such as a doctor or hospital -- to bill the insurance company directly and receive payment directly. By using this form, the provider hopes to avoid a situation where the patient may file a claim and be reimbursed by the insurance company, and then fail to pay the provider. The point is that a doctor or a hospital goes to great lengths to make certain that your care will be paid for.
When you enter the hospital and fill out the forms they give you, the matter of reimbursement is, in effect, out of your hands from that point on, save for any deductibles or cost-sharing portions of the total bill. The hospital accepts responsibility for collecting both the insurance company's share and the patient's share of the bill. When the hospital accepts that responsibility, you have a right to expect that the hospital will attempt those transactions within a reasonable period of time.

The hospital's main concern that drives this whole situation is the need for reimbursement. Hospitals end up holding the bag for a great deal of uncompensated care. Most people don't know just how many people receive free care from hospitals with the understanding that hospitals won't turn down anyone for care. So when a person has a means of paying, the hospital is anxious to collect.

On the insurance company side of the equation, your coverage should pay for expenses incurred under the terms of the plan while the plan was in force. Many insurance contracts state that claims should be received within a reasonable amount of time, though it is not necessarily common to see a 12-month time limit. The reason for this could be that insurance companies are required by regulations to set aside a certain amount of money for anticipated claims and keep that money set aside for past claims that have not yet been submitted. After a certain amount of time, the insurance company can adjust this reserve, possibly freeing up money for other needs or expenses. It would be interesting to know why the hospital failed to submit a claim for over a year.

The problem is that you feel caught in the middle. By promising (and then failing) to submit the claim, however, the hospital may have forfeited the option of coming back to you for reimbursement. It is not your fault that the claim was not submitted within the time limit, after all. In short, it looks like the hospital blew it.

In order to protect yourself, it might be a good idea to gather all the documents related to your hospitalization and share them with your attorney. Her or his opinion on the matter is crucial, and she or he can help you communicate with the hospital and the insurance company.