American Healthcare System Strikes Again

Over a year ago, I was diagnosed with cancer and had to have a medically necessary procedure done by a specialist out-of-network provider. The procedure in question was very time sensitive thus, the doctor’s administrative team informed me that waiting for an approved prior-authorization from my insurance company would take too long and would also most likely be denied. It is important to note that I receive Medicaid as I am a full-time student with limited income.

I was encouraged to pay out of pocket to get this done ASAP, after which I could file for a reimbursement claim with my insurance. Upon completing this procedure, while still battling the rest of my health issues, my PCP office filed for this special case prior authorization with my insurance. However, the dates they filed for were incorrect (future dates instead of the actual past service dates). Nevertheless, this prior authorization with the incorrect dates got approved.

When I reached out to see if the service dates can be changed, the insurance company told me it wasn’t possible. I would have to wait for the doctor to receive a denial to their claim, after which I as a patient can file an appeal (or my doctor can file on my behalf I think we did both).

After I provided them all the requested documentation, proof of payment, and explanation, they gave me the run around for an entire year. Each time I called I was told different information such as “your case is in progress, give it 45 days, 60 days…etc.” Then I was told my documents were never received and I would have to start from scratch etc.

13 months after my procedure, I finally received a denial to my appeal with the insurance stating that I signed the doctor’s waiver which acknowledged I would pay out of pocket. However, this was signed under duress due to the time-sensitive nature of the required procedure and my serious illness at the time. Additionally, I was informed that it was within my right to file for a Patient Reimbursement Request after this procedure was done.

I am now given the option to file a Complaint Appeal to this denial but I am concerned that they will just give me the run around again.

Any advice on the best course of action would be highly appreciated!!

Is there a specific type of attorney that handles matters such as these?

Thank you

submitted by /u/dramaqueen444
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