Can My In-Network Surgeon Legally Require Self-Pay Self-File?

First post here but I've been going nuts trying to find the answer to this question myself because there's so many adjacent topics that I keep finding results for instead.

I live in Oklahoma and last year had chest masculinization surgery in Arkansas. My surgeon made it clear before and at my consultation that they were strictly self-pay and self-file, which I was fine with. I had my surgery in August and submitted my insurance claim to UHC about 6 weeks later. I was rejected within a month, which I expected. When I reached out to find out the reason for rejection, they told me that because my surgeon was an in-network provider, he was the one who had to submit the claim in order for it to be reviewed. I reached back out to my surgeon's office to fill them in on this and they had their billing team send in my claim.

Less than a week ago, I got word back that my claim had been rejected again on the basis of not getting prior authorization. Now to my knowledge, prior authorization is submitted by the provider before the procedure – but I didn't even know that my surgeon was an in-network provider until I first got my claim rejected. When they said they were self-pay and self-file, I automatically assumed that they weren't affiliated with any insurance companies, something that seemed totally rational to me for a cosmetic surgeon. As a result, they don't have any of my insurance information on file because I never offered it – not that I really suspect that they would have pursued prior authorization if they did have it. Additionally, I also thought that a substitute for prior authorization is a letter of referral, of which I have two from two different care providers. I asked them if these referral letters were submitted with my claim but haven't heard back in a couple days, so I figured I'd try to educate myself some more in the meantime.

Here are the main questions I'm trying to get answered (and if you have sources, all the better):
Can a provider require self-pay when they are in my insurance network?
Does being self-pay and self-file have the implication that they're not in any insurance networks?
Is prior authorization only accepted when submitted directly from the provider to the insurance company?
Can my insurance leave me accountable to the entire balance when my plan (Bind/Surest) has a $5,000 maximum out-of-pocket contribution limit, and the surgery itself was $7,500?

I don't expect magic answers that will get my money back, and I knew there was a risk that my insurance wouldn't cover, but this whole situation leaves a bit of a bad taste in my mouth. I need to know if there's something shady going on or if I'm just uneducated on these things.

submitted by /u/ChiefHaven
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