Doctor showed in network on Aetna website but was actually off network

I began treatment with a new doctor in November 2022 and then in early December learned my company was switching health insurance providers beginning January 2023. I was worried the change could jeopardize coverage for an elective but medically justified surgery scheduled for January 9. My surgeon was listed as in network with Aetna so I decided to proceed with the procedure and the surgery center submitted my pre-authorization in late December which was approved by Aetna.

My surgeon doesn’t handle insurance payments so I needed to pay him directly and then file the claim with Aetna for reimbursement. The surgeon provided me with clinical notes and an insurance claim letter listing the CPT/IDC codes and costs which I submitted to Aetna.

I hit my annual in network out of pocket max paying for the anesthesiologist/surgery center so expected to be reimbursed for most of the surgeons fees but only received $1,500 of the $5,500 I had paid. According to Aetna, my surgeon actually went OFF NETWORK in mid-December. However, as of a week after my surgery the doctor was still listed on their website as being in network. I have time stamped screenshots documenting this.

I called and spoke with an Aetna rep that basically told me I’m SOL because the doctor went off network before my procedure and said it was my responsibility to make sure he was still in network before receiving treatment. He said it would have been possible to submit a transition of care request before the procedure but that’s not possible post op. He said I could file an appeal if I wanted.

My position is that 1) I had a reasonable expectation the doctor was in network since their website said so (they updated his status online after my claim lol), 2) had I been notified he went off network preop, I could have applied for transition of care coverage, 3) had transition of care been denied, I could have found a new in network surgeon.

Is there any chance I could get the procedure treated as in network in this situation on appeal or should I cash my $1500 check and move on with life?

submitted by /u/WhoRedditBetter
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