$0 responsibility?

Hi there – hoping someone out there can help with this as we’re at a loss.

My partner had surgery at an in-network hospital in October. We submitted the surgery to Aetna for pre-authorization, and it was approved, so we went ahead. We prepaid ~$6000 which was what was left on her out-of-pocket maximum at the time. However, when the claims were filed, they approved the surgery but denied the hospital’s other services – anesthesia, medication, and other general services – saying that there was no proof of medical necessity for them OR that these services were not pre-authorized – they can’t tell us which. However, they said our responsibility on this $10,000 bill was $0 and we have an EOB that states the same thing. (The amount paid to the surgeon was a separate claim. It was approved and we’re paying it – but we have now wound up paying MORE than my partner’s OOP max because the hospital claim was denied. If the hospital claim had been approved, the insurance company would have to pay the surgeon, because we would’ve hit the OOP max… at least, I think that’s how it works?)

When we called trying to find out what any of that meant, they said it’s the hospital’s responsibility to provide this proof or to submit these services for pre-authorization (whichever it is!) and they didn’t, so we can call the hospital and ask them to submit it. When we called the hospital, they said this happens all the time and they’ll wait for the insurance company to get back to them and then re-submit the claim.

However… that’s never happened and it’s now March. I tried to ask for an update but didn’t get much help – Aetna still maintains that our responsibility is $0 and that we can request a refund from the hospital.

My question is: is that even possible? I feel like not resubmitting the claim was an administrative error and I’m worried requesting a refund will mean they do resubmit the claim and we wind up owing more. But on the other hand, $6000 is a substantial amount to pay if we truly don’t owe $0. But on the other other hand, surely nobody truly owes $0 after a surgery lol. So I’m wondering if anyone else has been in a similar situation and what they did, or if anyone knows what might be going on? I feel like I can’t get a direct answer from either the hospital or Aetna, so I’m hoping someone can offer some guidance. Thanks in advance!

ETA: A few clarifying details and location is TX, US.

submitted by /u/coffeeandlyres
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