Payment denied AFTER surgery... should I be worried??

[GingersnapMI 29]

I have not yet received any bills for the two issues I'm about to discuss, just the EOBs (Explanation of Benefits). For non-US readers, this is a notice that an insurance company must send the patient whenever the insurance has received a bill. It explains to the patient about the bill: the medical provider, the service rendered to the patient, the charge from the medical provider, how much of that charge will be covered by insurance, and how much the patient can expect to self-pay.

My original surgery date was delayed/changed due to the hospital's COVID-related closure to elective procedures. I therefore ended up having surgery about 6 weeks after my original date. I just received the EOB relating to the hospital's $55,000 charge. The EOB states the charge has been denied due to "preauthorization was not obtained". I went through all the paperwork I've collected since my journey began and found the preauthorization approval notice for the original date of surgery... but it seems I never got a preauthorization approval notice for the new surgery date. Naturally, the surgeon's office has several people whose job it is to get insurance approvals/preauthorizations prior to surgery... I'm worried that the person handling my case dropped the ball...

The second billing issue concerns an EOB that shows I will owe $900 for the nurse anesthetist's bill ($500 deductible plus 50% copay). The anesthesiologist's bill was covered at 100%, but the issue is that his assistant (the nurse anesthetist) apparently doesn't participate with my insurance so I'd be responsible for the high out-of-network charges! Naturally, I as the patient only get to pick my surgeon... I don't get to pick the anesthesiologist or the nurse anesthetist or any of the nurses, for that matter. Again, the team used for my procedure is something that my surgeon's office and the hospital should have put together properly.

I called my surgeon's office a week ago and was transferred to the insurance specialist's voicemail. I've not received a call back. I'll try again tomorrow (Monday) but I'm worried... should I be?

I know a lot of people here have had their surgery dates moved around due to COVID, so this can't be the first time this issue has come up...?

I'd appreciate advice and opinions. Thank you!

Edited July 18, 2021 by GingersnapMI

[TinDE 83]

Does the pre op approval say how long it’s good for? Usually it says you have to have th3 procedure within 30/60/90 days

[GingersnapMI 29]

7 minutes ago, TinDE said:

Does the pre op approval say how long it’s good for? Usually it says you have to have th3 procedure within 30/60/90 days

It says it's good on the original surgery date. That's it.

[Soon2bFit21 109]

This sounds like an error on the part of the surgery center’s billing team. They would have to obtain a secondary prior auth if it was outside of the date range of your original surgery date. I would give them a call, most of these issues can be fixed and are due to incorrect billing.

[GingersnapMI 29]

Thanks, I've called my surgeon's office again and was again routed to a voicemail line. His $3000+ bill to my insurance was also denied due to no prior authorization obtained.

[RickM 1,752]

The first is likely nothing to worry much about, but to stay on top of - with COVID around I'm sure this is a common thing (though TinDE is right in that these things are usually pre-approved for some period of time, as delays happen. It is likely a matter of box checking and the surgeon's insurance coordinator needs to get with the insurance company to get the correct box checked on their forms so that their computer can do its job. It may even be routine enough that they don't even bother changing the pre-auth date rather than doing it retroactively. Again,, not likely a big deal, but it is their problem to work out - that's what they get paid to do.

On the second issue, this is one of the semi-legit "scams" in the medical world, where we get these trail of bills from out of network "providers" we never heard of. Kick this back to the anesthesiologist (why does he need a nurse assistant for a simple bypass job?) More and more various hospital workers, seemingly down to the floor sweepers, who used to be covered under a general surgical or anesthesia charge seem entitled to charge you insurance separately

My wife had an orthopedic surgery a couple of years ago and we got an EOB from a surgical nurse charging more than $16k (over double the surgeon's fee - for a half day job) of which the insurance paid $300.. We couldn't get any response from her billing service (an RN needing a billing service?) so we asked the surgeon about it in a follow up appointment (she must be damned good to bill double your rates!) and he texted her while we were there and the excess charge was removed by the time we got home. These underlings have an incentive these days to try to get away with what they can, but ultimately, they don't want to cross their boss - the guy who specifies their services.

Similarly, on a shoulder job I had, the insurance rejected the claim for a PA surgeon's assistant, claiming it wasn't necessary for that surgery; the surgeon told me "we'll take care of it", and they did.

In short, let the relevant providers know of the problem and let them take care of it before panicking, If it doesn't resolve within 2-3 months, then panic.

As a final note, let your surgeon know of any of these problems, as he is the ultimate boss, (or at least higher up the food chain). He may feign disinterest, (there's nothing I can do about that...) but anything that impacts the public perception of his practice is in his interest. He can't technically tell the anesthesiologist how to run his practice, but he does have influence over using his practice, so it may just be a mention over lunch ("Hey Bill, your nurse is hassling my patients again - have her knock it off...")

[qianmij 31]

Yes, something similar (almost exact) happened to me. I contacted my insurance company, not the hospital, and was able to hash it out. (Insurance failed to check a box or something and denied.)

[GingersnapMI 29]

UPDATE:

I called the number on the $900+ bill I had by now received from the nurse anesthetist's office. They told me to call my insurance.

I called my insurance and the wonderful lady on the phone stated that since I had my surgery in a participating hospital with a participating surgeon, all other bills should have been processed as in-network, even if the particular surgical team member (the nurse anesthetist, in my case) isn't actually in-network. She stated that it looked like several different people at the insurance company had handled the charges related to my surgery and the person who handled the nurse anesthetist charge had not "realized" that the charge was related to an approved procedure in an approved hospital. (Someone wasn't being thorough in the performance of his/her duties!)

The proper pre-authorization had been obtained and all charges will be, hopefully, processed/re-processed correctly and paid as expected.

I'm so glad that I know just enough about medical billing and insurance to be able to tell when something doesn't look right, and sometimes even be able to figure out why and therefore be able to argue it effectively. I pity the people who simply pay any bill they receive. I don't think a year goes by without me having to straighten something out concerning medical billing... and I've had several different insurances over the years so it's not just one or two particular insurance companies that are the problem.

Edited July 26, 2021 by GingersnapMI

[cheryl o 60]

UPDATE:
I called the number on the $900+ bill I had by now received from the nurse anesthetist's office. They told me to call my insurance.
I called my insurance and the wonderful lady on the phone stated that since I had my surgery in a participating hospital with a participating surgeon, all other bills should have been processed as in-network, even if the particular surgical team member (the nurse anesthetist, in my case) isn't actually in-network. She stated that it looked like several different people at the insurance company had handled the charges related to my surgery and the person who handled the nurse anesthetist charge had not "realized" that the charge was related to an approved procedure in an approved hospital. (Someone wasn't being thorough in the performance of his/her duties!)
The proper pre-authorization had been obtained and all charges will be, hopefully, processed/re-processed correctly and paid as expected.
I'm so glad that I know just enough about medical billing and insurance to be able to tell when something doesn't look right, and sometimes even be able to figure out why and therefore be able to argue it effectively. I pity the people who simply pay any bill they receive. I don't think a year goes by without me having to straighten something out concerning medical billing... and I've had several different insurances over the years so it's not just one or two particular insurance companies that are the problem.

oh my gosh, you're insurance took you for the scariest Halloween ride of your life! Im so glad its solved!! [emoji3060][emoji3060]

Sent from my SM-G973U using BariatricPal mobile app

[cellbell 113]

This whole practice of being billed for an out-of-network provider during an in-network procedure is starting to be banned in a variety of areas, with a federal law coming into effect in 2022. If anyone's interested, you can find more info here. I'm so glad it worked out for you in the end! I hate that we have to go through medical bills so carefully, but I understand that medical billing in general is super complicated and I wouldn't want that job!