Claims Problem

Good day! I am looking if anyone have any similar experience with me or if you guys can share your thoughts of what should I do.

I had a regular eye check up and they referred me to a retinal specialist since the doctor saw a tear/hole in my retina. We only have one clinic here in our state that have a retinal specialist. I have called my insurance if they can make it IN-NETWORK since I don’t have a choice since that is the only clinic I can go to. They said it’s approved as “IN-NETWORK LEVEL” of benefit. I went and found out I needed laser to close multiple holes as it’s already causing detachment. After a week they did the laser to close up the holes.

Now I have received the bill and they are billing me $5000 for the laser. Original price is $5,700. Insurance is only paying around $700. I was shocked since I thought this will be IN-NETWORK and I only have to pay the 20% since I already reached my deductible.

I called my insurance and they let me know that they did process it as “IN-NETWORK LEVEL” however, it exceeded the maximum plan allowance and that’s the only amount they can cover since the provider was out of network. What’s worst is that the amount the clinic is billing me won’t go to my out of pocket.

I didn’t really have a choice but to go that clinic since there’s no providers that are IN-NETWORK here. I was 7 months pregnant the time of the procedure and I definitely would not travel out of state just to go to a IN-NETWORK provider.

I do plan to make a claim but I was wondering if anyone has a similar situation and If there is a chance that insurance will pay for it.

Thank you!

submitted by /u/Aurora_Gwapa2024
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