At out of pocket max, still asked to pay copay, no refund
(Texas)
Last year, I was at my out of pocket maximum prior to a nasal surgery performed in the 2nd half of the year.
My understanding going into it was that the full amount was covered by insurance due to my collapsed airways in the nose, 95%+ restricted, etc.
Anyhow, I had several providers related to this surgery (surgical center, anestheseologists) charge me estimated copays even though I was at the OOP max. They said it was a requirement (even though I'm on an HSA, and card says they supposed to bill me) andthey refuse to do the work w/o charging the pre-payment).
I realized a week ago or so, I never got any refunds for this, so I checked my insurance EOB from last year, and sure enough, it came back as my owing nothing – 100% covered by insurance at the contracted rate (everybody was in-network for me).
I called up and got the invoice from the surgery center, and it shows that they got the insurance payments, and a few line items indicating at least $4,000 of their total bill was denied as medically not necessary (based on my limited knowledge, looks like some implants the surgeon placed to keep my airways open long-term).
On the paperwork, they basically wrote everything off above my pre-payment, so I didn't owe anything, but I also didn't get any of my pre-payment back.
Is this normal practice and/or legitimate? I was thinking about calling back and complaining, losing $700-$1000 total is not nothing… That being said, my other thought is that they could turn around and try to bill me for whatever insurance thought wasn't medically necessary. In my mind that could mean they might go after me for their billed $10k in order to recover $1000, cutting my nose off to spite my face.
I could have potentially fought the assessment with insurance – I've done it before, and successfully gotten procedures covered, so there was at least a non-zero chance that I could have again had success. My EOB explicitly states "You may owe: $0.00" FWIW.
Difficulty Level: Hard: less than 30 days after my surgery, unknown to my surgeon at the time of surgery, the system closed the ENT office entirely. They were notified mere days after my surgery! So, no wonder it wasn't appealed within the 45 day window. I of course had no notification of this from either my ENT (duh, they got closed), or the surgery center (who is still open).
Thanks!
EOB Text
(1) This is not covered. Your plan covers services that are necessary. The U.S. sets standards for safety and effectiveness for diagnosis, care, or treatment. This does not meet that standard. If you and your provider have been notified that a service is not covered, but you sign an agreement with your provider to pay for non-covered services, your provider may bill you. [790]
(4) To consider this charge, we need your provider to send us:
Clinical documents that support the medical necessity of the billed service. This includes drugs, medical equipment and implants. The diagnosis and the expected time you'll need the drug or equipment. Copies of your current history and physical exam, office or nursing notes, operative report, photographs, lab or diagnostic testing results or air ambulance records, if any of these apply. A complete description of the service and the itemized bill, if your provider billed an unlisted code. Your provider has 45 days from the date of this statement to send us the information. When we get these details, we'll decide within 15 days. If we don't get it, we'll deny the claim. You will have a right to appeal the denial at that time. The following does not apply to Federal plans: For claims sent from NC: you have 90 days to send us the information. If we don't get it, we'll deny the claim. For claims sent from Texas: if we don't get the information, your claim may remain open. [U33] submitted by /u/novasbc
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