Denial Based on Administrative Decision – not clinical
My wife had a fall, out of state, while hiking back in December 2022. We went to an “in-network” urgent care for X-rays of her hand and was treated for a fracture (splinted). Our plan covers UC visits in full with a $20 copay for in-network providers. We received a bill several weeks later for 40% of a $1,500 UC visit bill, so a little over $600.
I contacted both our insurance and the UC to inquire. Our insurance states that the office billed as an outpatient surgical visit for fracture treatment…The urgent care states that they do not bill as an urgent care because they are not licensed/acknowledged as an urgent care in the state (CA – this is affiliated with a large hospital system and was in our insurance app’s in-network providers “near me” and also has giant red Urgent Care signage on the building). We have attempted multiple appeals without success and our insurance states that the appeal is being denied on administrative grounds due to the billing/coding of the provider we were seen at…even though all of the documentation from the visit clearly state URGENT CARE VISIT.
Super frustrating and it is now 8 months from time of service and have been working with a health advocate group but still no dice. Any advice on any other options we may have for this surprise bill? We requested an external appeal which was denied and are being recommended to begin fee negotiations…but it is mind boggling that we are getting footed for a bill based on stubborn administrative reasons outside of our control. Any advice would be great.
submitted by /u/njatc
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