Insurance "didn't pay for the surgery" even though I was approved.

So I had surgery 19 months ago with Dr. Elariny. I paid $12,000 up front. I was pre-approved by BCBS for the DS with Dr. Elariny. Alex, the coordinator, said everything was good to go in terms of payment from the insurance company, and I would likely receive a sizable refund after it was paid. She said the insurance would pay for the surgery. Otherwise I would not have had surgery.

  I don't hear anything from them for a few months, so I call. Was put on hold with their "billing department" for 15 minutes, where I could hear things breaking in the background and people yelling. Random. They said they'd look into it.   Fast forward to 8 months post-op. Called and emailed, they said the claim was never submitted so they'd have to do it again and it would take "several months".   14 months post-op, I email them and was told that their billing department was looking into it.  

19 months later, I email and call again, and their billing department said I owed them $23,000 because my insurance "didn't pay". I asked them to resubmit it, they said "pre-approval, pre-authorization, does not guarantee payment" and that I had to pay the remainder because they are "out of network". However my insurance pre-approved it and had out-of-network benefits. Their billing department replied and said that "insurance doesn't guarantee payment" - no duh. That's why I got Alex to confirm that it would pay FIRST! Ugh!

They are saying I have to prove otherwise. I'm livid. They should have figured this out before surgery.   Why bother getting prior-authorization & pre-approval if it's not a guarantee that the surgery will be covered? I jumped through all of the hoops for what reason? I could get prior-authorization and pre-approval from a random person off the street if it doesn't mean anything.  This is 19 months after surgery and they are just now realizing that I "have to pay" really? They never sent me any final bill, any final statement or anything.   

What's my recourse here? Their billing department seems incompetent and unwilling to help me. I can't pay 23k and I could barely pay the 12k to begin with. I was able to borrow because they told me that I'd probably get 3-5k refunded.    My family wants me to drop it, to call it a loss and move on, declare bankruptcy if they pursue it. I think this is borderline fraud and I know they are doing this to others. I know of one person on the OH Facebook group who is in a similar situation. I need more information about the pre-approval/prior-authorization part though. 

I'm trying to get the old information together, but since this issue came up 19 months after surgery, I no longer even have access to my old insurance statements online since I dropped that insurance shortly after surgery. If they told me about this at a decent time, this could have been easily taken care of. I can still get the info, I just have to wait until I next Wednesday to call since I work during their business hours. It's so frustrating.

Edit: Sorry for the formatting, I seem to have lost my paragraphs somehow. Fixed now I hope!

I would talk to a lawyer and get them to draft a letter to the company for clairification. To me pre-approved means pre-approved.  the company is just hopeing you will go away, don't let them get away with it.  Good luck Barb

 If insurance won't pay, they should be able to say why.  If it has to do with paperwork not coming to them, then you have something to work with for sure.  Start with the insurance company, then follow up with the office manager (not insurance person) at the docs office.  Start first by explaining that you are trying to get them paid by the insurance company and avoid bankruptcy.  The manager will understand the business aspect of an anticipated loss like that.

I had jaw surgery to the tune of over 40K last spring...had the pre-approval number and letter filed away. I got notice that my claim was denied...found out it was CODED wrong. Once coded correctly, I had to only pay the co-pay (less than $300). I am on Humana Medicare Advantage and the lady told me that a pre-approval means that they are suppose to pay.

However, coding errors will get it tossed every time.

First, find your EOB if you have it. If not, check your insurance company web site to download it. Then call the claims dept at your insurance company...get them to tell you what THEY have and why something is not paid if the EOB is not there or was denied. Then call the Billing Dept who submitted the claim for surgery and find out what they put...if necessary talk to a supervisor not just a CSR.

Be a squeaky wheel!

Liz

BCBS did the same thing to me.  Of course my doctor sent me a bill within a few months of surgery so I knew right away something was not right.  I even called the Authorization department a few times to confirm auth approved prior to surgery so I was super surprised when my claim denied.  

In my case the auth area was moved to another department.  My surgery was approved in error in the old auth department (strange I know).  I told my doctor to submit medical records ASAP.  Luckily mine was approved with medical records but i was told it not approved I would have to pay.

Did you get a preapproval letter?  Did your surgeon submit medical records?  (also it doesnt matter that you no longer have that insurance - I work for WellPoint and we look at active member claims as well as termed members - - no special treatment for active members).

If all else fails - send your issue to the Insurance commissioner. 

 I would check with the insurance co and see if it was a coding error I had surgery and the hospital billing dept kept coding it wrong for 9 months, one month no code, next month I gave birth NOT, following much surgery on a differnt part of my body and so on. I knew it was the hospital error because the insurance up to this point had paid every bill I got and paid it without a problem. Also I thought after a certain amount of time the doctor's office was out of luck if they didn't bill you, but I could be wrong. Hope it all gets streightened out for you.

So, manditude, what going on now with your bill?

Mandi,

Do you get this resolved?  I am having the same issue.