CPT Missing on Prior Auth

Hello!

I had a surgery last December; getting fully reimbursed for it has been a nightmare. I could use some help.

The surgery was a brow bone reconstruction. I went out of network since the in-network waitlists were multiple years. My insurance (BCBS MA PPO) said they’d cover it using my in-network deductible and coinsurance rates so I went for it. This however meant that I needed to pay the plastic surgeon the entire fee up front.

The surgery went well. The insurance company refused to reimburse me because they wanted receipts. I sent the receipts to their agents four times, and they never actually re-processed the claim. Months later, I tried sending a dispute via certified mail and it worked.

The surgery cost $15k. The final bill had two CPT codes, one for 10k and one for 5k. They reimbursed me for the 10k procedure, but denied the 5k procedure. They said the provider never included it on the prior authorization.

The approved prior authorization on the insurance website only lists “gender affirming services”.

I reached out to my HR departments insurance liaison. They said the provider forgot to include one of the procedure codes on the prior authorization and I should ask them to re-submit it. I asked them to make an exception since it’s a self funded plan and they said no.

So I contacted the surgeons office. They told me they’ve been working on it for over 2 months now. I touch base every week or two, and they say they’re still working on it. They asked for more details a week ago, so maybe they’re actually working on it. However, my initial email was plenty clear.

My understanding is usually an in-network provider would be forced to eat the cost in this scenario. But I went out of network and paid up front.

Am I screwed? Is there any recourse I can take?

Thanks for the help! 🏄‍♀️

State: Employer is in Massachusetts. Surgery was in Massachusetts. I lived in Washington state at the time. I currently live in Illinois.

Age: 27

submitted by /u/oatmilkapril
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