Got a surprise bill for Spravato (esketamine) services because my doctor was in-network for ‘behavioral health’ codes but out-of-network for ‘medical’- what are my options?

I’m in a frustrating situation with this, would appreciate any advice on what to do or expect. I’m in California, and I have United Healthcare insurance with OptumRx. I’ll bold what I think are the most technically relevant parts.

I have a long history of treatment resistant depression, tried many meds, did TMS last year, which helped but didn’t resolve the problem. This spring, my in-network psychiatrist who is also my therapist told me that the clinic I see him at had reached an agreement with United Healthcare to offer Spravato treatments. Spravato is a prescription nasal spray with a form of ketamine that is approved for treatment resistant depression, but because it’s a controlled substance it has to be administered in office, and patients have to stay for at least 2 hours and have their blood pressure monitored. They got the prior authorization approved, and because my doctor is kind of expensive and I see him a lot, I had already hit my in-network out of pocket max, so before starting treatment they had me sign a document showing my co-pay was estimated to be $0. Treatment works as follows: you go twice a week for 4 weeks, once a week for four weeks, then biweekly after that for maintenance. The total billed cost of each visit is about $3000.

Good news and bad news- the treatments are working great! I went from ‘severely depressed’ to ‘mildly depressed’ and I’m working through some trauma, working on getting a job, etc (my insurance is COBRA from a job I quit last year). Bad news: Two months after getting my first treatments, the first claims actually hit my UHC account as Pending, then Approved, but as out of network.

I was deeply confused, because these were the same exact doctors and same exact office I was already being seen at in-network, and they were confused because they had other UHC patients whose Spravato claims were processing fine as in-network.

After a few phone calls with the doctor’s insurance specialist and with United, I got a slightly clearer picture: Since Spravato is a weird mix of medical procedure/prescription drug/mental health treatment, the billing codes are complicated and each insurance company does it a little differently. My understanding is that there are ways to bill it under ‘behavioral health’ codes and ways to bill it under ‘medical’ codes, and United has them bill it under ‘medical’. For their other patients with United insurance, this is fine, but my exact plan has my doctor as in-network for ‘behavioral’ and out of network for ‘medical’. I think it has something to do with having Optum for prescription drug and maybe behavioral health coverage.

So two months after starting treatment, I get hit with the surprise news that I now owe my out of network out of pocket max, which is $6000. I’m unemployed in a VHCOL city, and while I do have that amount in my HSA, I was hoping to get reimbursed for claims I’ve already paid and use them for living expenses.

My doctor has been sympathetic, was as confused and surprised about all this as me and agrees that it’s ridiculous to expect me to have understood any of this in advance of treatment when it took 8 weeks for the insurance company and their biller to figure it out. I did TMS with them last year, which was covered in network (I guess as ‘behavioral health’ even though shooting magnetic fields into your brain seems pretty ‘medical’ to me). **I think if it were solely up to him, he would just waive the $6000 **as that’s honestly a fraction of what my insurance has paid them so far this year alone and it doesn’t feel fair to put me on the hook when they told me they thought it would be a $0 copay. But I understand they have some obligations to the insurance companies to actually charge patients the amounts they say they will to meet their deductibles etc.

He told me my next step should be to fill out a financial hardship document with his office, as that will let them waive some percent of the charges, then we can figure out with the clinic director if it’s possible to discharge it somehow.

My questions are as follows:

1: If the clinic waives all or part of the $6000 I owe them, does my insurance know about that somehow? I have a high deductible plan, $3000 deductible for OON and $6000 out of pocket max. Treatment is ongoing, so if they waive it for previous treatments but I still have to pay for future ones, there’s not much point unless I can also convince them to treat it as in network. I think there are ways to do that if there are no other in network providers accepting patients in my area, but I’m not sure how long or painful a process that is.

2: We got prior authorization for this service back in April/May, before we started. I saw that letter in my myUHC account last week. Today when I logged on to read the details of that, I saw that the previous letter was gone, and a new prior auth letter dated 7/19/23 was there. There is a line in the letter saying to use the cost estimator tool on their website, but it doesn’t find anything for the code they provide or anything about esketamine or Spravato, either in the general cost estimator or the behavioral health cost estimator. Should I request a copy of the previous prior auth letter? Is there any chance the previous letter had different information that might be relevant, like a different procedure code or calling the procedure in network or providing an actual cost estimate based on it being in network?

3: Before we got the information about the medical/behavioral in/out of network issue, my doctor had suggested going to the California Department of Insurance and filing a complaint. It’s hard to see technically what UHC did wrong here, since I don’t know the details about how billers estimate costs and submit claims etc, but if they should be accepting these claims through ‘behavioral health’ codes as it is a depression treatment, then it would be in-network for me. Would the Department of Insurance be able to help?

4: Any other ideas or suggestions of what to do or who to contact? It really feels like BS that I should get blindsided by this bill because United prefers to get billed this way, and unreasonable to expect me to know the intricacies of medical billing in advance when I’d already gotten so much in-network care from them and their other United patients had no issues.