Hello, please bear with me; this is a long story and I have been to you-know-where and back with all of the phone calls and emotion.
I received an order from my doctor for a CT scan in December, at an outside facility which required preauthorization (didn't know this at the time.) I never received any indication things were awry - no letters of denial or anything. However, I did call the facility five days before, to ask what my cost would be. They quoted me (as an example) "$200.00," which was the exact remainder of my deductible for the year. So this sounded like they had contacted my insurance to know that exact amount. I figured everything was ironed out with it being authorized.
Shortly after the scan, the facility sent one statement that said "not a bill" but had a "pending" total of $200.00 and a link to pay the bill by credit card. Even though it said "pending," I knew this was the remainder of my deductible and went ahead and paid, to get it off my plate.
The $200.00 was never applied towards my deductible. I also never received another bill in the mail. My insurance dashboard shows date of service, cost to me as $0.00 and "approved." I didn't look at the detailed EOB because the dashboard entry said approved.
A couple of months pass and I call facility billing to ask why the $200.00 was not applied to my deductible. I was told, "I see you've paid $200.00 and your balance is $0. But your insurance didn't cover it. You have to go to collections!" Like I tipped her off to my own outstanding bill. Stupid!
I said "please hold off on that until I can do more research." I still have not received an official bill in the mail. Seems strange to send me straight to collections?
I looked up my detailed EOB, which says: "Hospital charges= $1,000 Your discounts= –$1,000 Due to your hospital=$0.00 Anthem paid=$0.00 Copay=$0.00 Deductible=$0.00 Services not covered=$0.00 Your total cost=$0.00
\182 The service(s) you have performed require a pre-authorization/referral. We are unable to pay this claim because a pre-authorization/referral was not obtained."*
I found out from the ordering doctor that they submitted the preauthorization to the facility, but the facility apparently did not submit it to insurance. The facility dropped the ball. The ordering doctor "didn't think to check" if the preauthorization was approved.
The ordering doctor tried to resubmit the authorization to insurance, but it was not accepted.
The doctor said they should have checked on the preauthorization, but they didn't. They even said that they knew they messed up, and are using my case to train their department so this doesn't happen to anyone else. They are admitting some kind of fault.
Do I owe a bill for a procedure that happened 80 days ago if I haven't received anything in the mail other than the first "not a bill/pending" $200.00 document that seems stuck in lala land? (Not applied to deductible, but not refunded.)
I have read several reddits that say in some states the provider has to obtain preauthorization, and if they don't, they can't bill you. But I can't find any official law that says this (I'm in Georgia).
I have called insurance to ask about this, and all they said was that I can appeal. But my "total cost" says $0.00. What do I appeal? What is going on?
My story sounds very similar to this one, but there is no follow-up. https://www.reddit.com/r/personalfinance/comments/6pkvux/medical_insurance_claim_question
Thank you in advance for any helpful responses.
Submitted March 08, 2019 at 11:19PM by leafygreens https://ift.tt/2F0hYhB
