Florida Blue – C-Section Doctor messed up authorization – getting full bill

Redoing a previous post as data has cleared up – deleted that one.

Hi, I was hoping someone could share their wisdom and recommendations.

Long story short – we had a healthy baby through a C-section a couple of months ago. Most medical claims have come through without a problem. However, the Obgyn that operated, the anesthesiology, and another doctor that performed – it has all been denied – while all being in network.

I have called the insurance multiple times, and their explanation is that the procedure is covered, but the doctors must submit the correct documents. I was able to collect that initially, an observation authorization had been granted, which made no sense, as we were there for a baby delivery.

For sake of the case, let's say the baby was born 04/02 closer to midnight. That initial observation authorization wasn't applied – on 04/03 the obgyn's requested another authorization, this time for the c-section, but only included 04/03-04/05, not the actual birth date.

The Obgyn has submitted the claim 4 times, and 4 times it has been denied. After the latest explanation from the Insurance, it is clear the provider messed up. However, the insurance says I can't do anything about it, and that the provider needs to fix it. The provider for their part have now sent me the full bill. I have called them to explain, for like the 5th time, that their request was done incorrectly. While they have said they'd look into it, I am concerned as I have little influence over the process.

Do providers have a process to amend these dates? As it's the provider's second authorization through which the other doctors also go through, and have been denied, I am guessing I will be getting invoices from them.

Do I have any legal recourse here? They are all in network, and the procedures are all covered, but the insurance said that for any inpatient procedure an authorization is required and evidently the provider did not include the right date on the authorization. Given it's been over 60 days on this, I am getting concerned there might be a time lapse factor.

I understand I can always claim damages on this, but doesn't seem like the smarts path with doctors who did a great job.

Has anyone had a similar case and resolved it successfully?

submitted by /u/Ac4m2
[comments]