Claim for wife’s knee surgery was denied. In appeals now and need input on next steps.
My wife had knee surgery back in April 2023. We were told before the surgery that the procedure was covered. After the surgery, the facility fee of $32k was denied by our insurance because it was missing a prior authorization. We filed an appeal to resolve this, but I am concerned about what could happen next.
My question: If I change health insurance plans before the appeal is completed, will the insurer still be obligated to resolve this since it happened while we were covered by their plan? Will switching insurance put us in a detrimental position at all?
Context: I got laid off from my job in August. I am paying for cobra coverage until I can find a new job. I'm in the final stages with a few companies so hopefully I will have a job + new health insurance soon.
What's odd about this: Health insurance paid the doctors charge ($1100) and anesthesia charge but not the facility fee ($32k).
Full sequence of events: – Fall to Winter 2022: wife develops knee issue. She goes thru several non-operative treatments but they all fail. Surgery is recommended by non-op doctors. – 2023: she sees a surgeon and tests are performed to confirm that surgery is needed. His office calls our insurance to confirm that it's covered and no prior authorization is needed. – April 2023: she has surgery – May 2023: we receive a summary of health plan payments letter stating the $32k claim is denied bc it's missing a prior authorization. They inform me the hospital still has 90 days to correct this – May to July 2023: I call my hospital several times to inform them of the 90-day deadline and ask about the status of the paperwork. Everytime, they tell me our case was escalated to the insurance denial claim, but this team does not talk to patients. – August 2023: the deadline passes and the hospital still has not responded to the insurance's request for paperwork. All I am told is that they are working on it. My state dept of insurance and my insurance company recommended filing an appeal to resolve. And now where we here.
submitted by /u/naz8587
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