URGENT: Hospital made errors on claim and took too long to provide medical records so insurance denied claim. Insurance saying I have to pay full facility charges! What are my options?
April 5, 2023 I had abdominal surgery to remove a 20cm fibroid from my uterus that was causing me to bleed profusely for two months, get a blood transfusion, iron infusions, and the resultant serious anemia was interacting with an existing health condition that put me at very high risk for complete vision loss. It was a very traumatic situation and the surgery was urgently needed. I received prior approval from Anthem BCBS for April 5 – April 7 for surgery and hospital. In addition, I had a good faith estimate prior to surgery which showed my responsibility as being only a couple grand. I had surgery on 4/5 and had a complication or bad reaction to anesthesia, no one seemed certain. A neurologist was engaged and I was perscribed some scary new meds that came with some serious side effect warnings. At least it stopped the puking but I wanted to know if I could stay another night for obervation. Nurse was like sure. I had never had surgery before and was not in my right mind. I was barely able to keep fluids in me, had constant diarrhea, and could only sip broth and nibble on crackers. If I ever knew about patient advocates before hand, I would have asked for one then. I never even imagined this would cause such a stink later though. Well fast forward a month later, 5/2 the hospital submits claim to my insurance with obvious ERROR. They used service dates of 4/4 – 4/8. This should have been 4/5 – 4/8. In addition, apparently as I would find out later hospital never let Anthem know I needed to add additional day to my preauthorization. Anthem replied back 5/10 to my hospital that they needed full medical records (according to my EOB) and per ERISA had 45 days to comply. Hospital did not comply and I received another EOB and email from Anthem on 6/20 stating claim was denied due still waiting on requested info/documents from provider. Now at this point, my EOBs still said $0 due from me and both still showed the WRONG service dates of 4/4 – 4/8. Finally, a decision was made on 6/23 apparently and I received a final EOB on 6/25 stating, "claim denied: Waiting on claim from related provider. See plan policy for benefit coverage/limitations/exclusions" and I WILL OWE IN FULL WITH NO DISCOUNTS MY ENTIRE FACILITY BILL OF $23,961.00! Also oddly enough the service dates now showed 4/4 – 4/7, wrong! I have already met my plan deductible and my out of pocket max. So per my plan my insurance carrier is 100% responsible for further medical claims. My hospital is in-network also so they should be I believe contracturally bound to submit claims in a certain timeline I think. Not to mention isn't this considered "surprise billing"? Well, I at first called hospital billing dept, and was told most recent claim was denied to "not following plan procedure". She didn't say who didn't or how, but asked me if I had perhaps seen a different provider. I told her no I had not. I then pointed out to her that I had also had been discharged from the hospital on 4/8 instead. She couldn't help me except to say call Anthem. I called Anthem and they put me on hold to talk to hospital. Rep came back to me to tell me this: hospital saw same errors but it will take ANOTHER 30 days to send in another authorization request and once that is done, then they have to resubmit claim. When I asked Anthem rep do I have to submit an appeal she said no. I called Anthem a second time and the second rep wouldn't even tell me if I should. I need to know what to do??? What are my options please time is running out. Am I seriously going to have to pay this in full?
submitted by /u/StayStrongGirl83
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