Doctor’s office misled me, now what?
This is not strictly a health insurance question, but I’m not sure what other forum has as many people who are knowledgeable about the US healthcare system.
I have an HMO through UHC. In March of this year I visited my OBGYN (not my PCP, but treated as one from a benefits perspective on my plan) to see if an issue I was having might be related to the hysterectomy I had last year. She checked me out and everything was fine from her perspective, so she referred me to an appropriate specialist.
I saw the specialist (PA) for an office visit in April and paid my copay. Options that might work for my condition were discussed, and she thought I was a good candidate for one procedure in particular. She wanted me to come back and have a visit with another provider in the office (the MD who actually performs the procedure in question) and led me to believe that the visit would be a discussion with him, and that he might want to do a related scope on me but she wasn’t sure. The claim for this visit was paid without issue.
The follow up appointment was scheduled for May for – I thought – another office visit. I came in and was directed to a different area “for a scope.” I said that I was told the scope was only a maybe, and they replied that the doctor definitely did want to do it. So it was done and everything was fine and he said they’d call me to schedule the recommended procedure. At that point I asked whether they would take care of getting authorizations for the procedure and the person was like “oh it’ll just be covered as part of the office visit, it’s fine.”
I got the EOB for the May visit/scope and it was denied. Weirdly, the verbiage was for “out of network care,” even though the doctor is in network, but then it went on to say that the services had not been properly preauthorized. And of course I immediately realized my mistake. I’m just so spoiled by my PCP’s practice always taking care of everything that I forgot that this visit hadn’t started that way, and I should have asked him to do a referral to the provider I was going to see. But I was thrown by the fact that they paid the April visit with no issues. I filed an appeal and mentioned that, that the May visit was a continuation of the care begun in April, but no dice. They denied it again.
While I realize I could try to keep fighting this with UHC, I don’t know that I will ever be successful because clearly the appropriate authorization was not obtained in advance. I do feel some responsibility for this and it sucks that I made such a rookie mistake.
I feel like the appropriate path for me to go down is arguing with the doctor’s office. They had my insurance information. They knew I had an HMO and that HMOs require auths for everything. I’m also a bit put out by the fact that the PA didn’t just tell me the MD would want to do a scope. Making it sound like it was only a possibility made me think that it would just be another routine visit, and if the scope was needed it would be scheduled. (I had no idea it was something so easy that it would only take some topical numbing and less than 5 minutes.) I feel like we are pretty much equally at fault for the claim not being paid, and as such I feel like splitting it 50/50 with them is fair. I’m just not sure how to approach it. Has anyone ever been successful with something like this? What do you recommend? I appreciate any advice you have to offer. Thank you.
submitted by /u/lollipopfiend123
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