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  1. #1
    Join Date
    Nov 2009
    Posts
    14

    Exclamation Told that Insurance Would Cover a Procedure, but Coverage Was Denied

    My question involves collection proceedings in the State of: California

    I am being pursued for a $12K surgery facility fee from an ASC. When the surgery was scheduled with the ASC, they took my insurance info and said it would be covered. After surgery, the insurance company denied the claim and I got billed for the full amount and now being sent to a debt collector. The physician, who owns and operates the facility, accepted the physician allowable amount from the insurer.

    Questions:

    Does the provider have any legal requirement to inform the patient that a procedure is not covered by insurance?

    Does the provider have any legal requirement to give an estimate of costs when they are this substantial?

    How do I determine what is normal and reasonable billable amounts for the codes I was billed for (these are facility codes, NOT cpt codes)

    Any help here would be appreciated.

  2. #2
    Join Date
    Sep 2005
    Location
    Behind a Desk
    Posts
    98,846

    Default Re: Told that Insurance Would Cover a Procedure, but Coverage Was Denied

    Exactly who is "they"? (The only "they" who can bind your insurance company is your insurance company.) As a general rule, it's your obligation to check your own insurance coverage.

    The claim was denied on what basis?

  3. #3
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Told that Insurance Would Cover a Procedure, but Coverage Was Denied

    1.) Unless your insurance policy specifically and in so many words says that it is the responsibility of your doctor to determine whether a procedure is covered by your insurance, then it is YOUR responsibility to determine it. Not his.

    2.) No. What stopped you from asking?

    3.) That's between you and your insurance company.

  4. #4
    Join Date
    Dec 2008
    Location
    Calif
    Posts
    289

    Default Re: Told that Insurance Would Cover a Procedure, but Coverage Was Denied

    Insurer Refuses to Pay Facility Fees to Surgeons: http://www.outpatientsurgery.net/new...es-to-Surgeons

  5. #5
    Join Date
    Nov 2009
    Posts
    14

    Default Re: Told that Insurance Would Cover a Procedure, but Coverage Was Denied

    The "they" is the provider who is 1) the physician who honored the insurance payment and 2) the physician as the representative for the surgery center who did not honor the insurance.

    There has to be some level of consumer protection here, doesn't there?

    The patient is at a severe information disadvantage. Are you implying that the patient has to go back and forth with the provider and his insurance company over every line item billing code that may or may not be billed in advance of a surgery? Where do you even get this info from and who is going to give you the time to go over all of the potential billing details. When you schedule a dr. appointment, do you also have to schedule an appoint with the billing administrator or a conference call with your insurance company. This doesn't seem right. How does the patient even know the right questions to ask until after the fact.

    Thank you all for your responses

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