Gap Exception Approved and PAID with $0 Patient Responsibility Surgeon won’t refund full prepayment.
Hi! I had a specialized lung surgery a few months ago that the surgeon I worked with files a gap exception for. I signed a contract that said I'm not allowed to reach out to my insurance or file anything without their express written consent and that they will handle all of the billing to get my gap exception approved. The office required me to wire $20,000 upfront for the main surgeon along with an additional $6,000 for the assistant surgery that they chose and required to work with the main surgeon. I signed a contract that says if they receive ANY money from my insurance that is in excess of $50,000, they will refund me the prepayment amount ($26,000 total). I never signed any contract with the assistant surgeon, only the main surgeon since they said their billing was combined. I reached out to the assistant surgeon's PA and asked for a full billing breakdown and what their policy is only to be told they are complementary and the prepayment is combined with the main surgeons under the same parent company?
Fast forward to post surgery, I get a notice from insurance that my gap exception was approved and that they paid my surgeon company over $175,000 (!!) with a patient responsibility of 0. I was so excited that I was getting the full $26,000 back since I had no deductible or coinsurance. I reached out with the EOB when the office said that I was absolutely due a refund and that they would send me $20,000 (only the main surgeon's payment) back to the bank account I provide. They're not including the $6,000 since that is a separate surgeon (??) I looked on the EOB and it says BOTH surgeons name on it. My insurance paid both the main surgeon and the assistant, with patient responsibility 0. I should be owed the full $26,000 back.
My contract separated the amounts, never actually writing $26,000 as the full number for the pre-payment…but it states $20,000 and the additional 6,000 is what my pre payment consists of… When they say that any amount from insurance excess of 50,000 they said they would refund the whole prepayment without specifying that it was $20,000 OR $26,000.
Do I have leverage considering my patient responsibility is 0 and they were paid 3x the minimum they needed? And that the assistant AND the main surgeon's name are on my insurance claim? They're not allowed to collect money from the patient then right? If insurance said they paid them?
Is this small claims court? Or getting a lawyer??
submitted by /u/bocalocadoca
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