Large cash pay fee to in-network surgeon/double billing

Hi all, I (24F, Pennsylvania/NJ) had surgery in April with a provider who is “in network” with my PPO plan. The office required a $12,500 surgical fee up front before scheduling me. The office provided a list of billing codes and diagnosis codes, I called my insurance company with the list and I was told all of these procedure codes would be covered with the diagnosis code and encouraged me to file a claim for reimbursement with the documentation and receipt.

The insurance agent also noted that it is against the surgeons agreement with the insurance company to double-bill for these services and to collect payment above my copay and deductible (which I also paid, $1086 deductible). I do have documentation that shows the surgeon submitted a claim with these procedure codes and was denied and paid $0. However, I did not receive an EOB or any documentation from the surgeon nor my insurance company that references this claim that shows up on the portal. I do have an EOB relating to this surgery that shows a claim on behalf of the hospital for my care there, but does not list the surgeon.

I’m currently waiting to hear back from my insurance on a determination, but does anyone have experience with trying to be reimbursed for cash-pay with an in-network doctor? And any advice on what may help my claim?

submitted by /u/adamsandlersyndrome
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