Dr. said I had prior authorization, but insurance has denied coverage of $40k surgery
Hi all. Having a bad day over here. For reference, I have marketplace CareFirst that’s reimbursed through my employer. In January, I had excision surgery for endometriosis. My surgeon was out of network with all insurance. The understanding was that I would pay some thousands out of pocket, and the hospital services would be covered by insurance after receiving prior authorization. The doctor’s office scheduled me for surgery after they said they had received prior authorization.
The night before the surgery (as I’m suffering through colonoscopy prep lol), the hospital calls me frantic saying that my insurance denied my surgery and said I should call my doctor. I call and the administrator emphatically says that they’ve been on the phone all day with CareFirst, that they’ve received all the prior authorization necessary for everything to go forward as planned and can share the codes with me, and that they would never send me to surgery without authorization. I was confident everything was good.
I just got notice today of a final appeal decision and final adverse benefit decision on my claim that the hospital filed on my behalf. CareFirst said that the services I obtained were not pre authorized and so my claim is denied. The total charge for the service is $40,368.45. I didn’t even know this was going on, because this is the FIRST time I’m hearing of it from the hospital! I haven’t received a bill yet, and I’m not sure what happens next. What do I do?? Who the hell do I call first?? I’m actually numb with shock. Does anyone have any advice?
submitted by /u/mmhatesad
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