Health insurance "made a mistake" on 2 claims a year ago and now wants me to pay thousands (Massachusetts, USA) Insurance

I have an employer sponsored health insurance policy in Massachusetts, and a chronic health condition which requires regular treatment from a neurologist.

I had the same procedure in my physician's office (which is located within a hospital) on three dates, March 2023, June 2023, and August 2023. My health insurance provided prior authorization before any of the procedures took place, and I had the same coverage throughout the whole year though a new policy year began in July. My provider's office billed the procedure identically all three times, but my insurance invoked a $500 copay for the 3rd visit only in addition to charging my full deductible.

I had dozens of conversations with insurance reps and my provider's billing office over the course of several months, and all parties expressed confusion about why the 3rd visit was processed differently. I then filed a formal appeal with the insurance company (December 2023), which ultimately denied the appeal and upheld their decision (January 2024).

In January 2024 I then filed an external complaint/appeal with the Massachusetts Division of Insurance (MA DOI) (as was noted in possible next steps in my appeal denial document). After receiving the complaint from MA DOI, the insurance company then reprocessed the original 2 bills from March and June 2023 and provided an updated explanation of benefits in February 2024 which applied a $500 copay to both visits in addition to the full $2,000 deductible which they had previously claimed I had already met.

In the insurance company's response to MA DOI, they stated "My review shows we did not process the claims for dates of service March 2023, and June 2023, correctly. We processed the claim for date of service August 2023, correctly."

I simply would not have had these procedures had I know they would cost me this much. I especially would not have gone 3 times had I received the "correct" bill after the first visit. While I believe that in MA insurers have 12 months to reprocess claims, the insurance company's alleged mistake for the processing of the first two procedures caused me to make different decisions regarding my health care that I would not have made had they made the "correct" processing the first time. In total, I now owe over $5,000 for these 3 visits, after my patient responsibility had initially been $0 for the first two procedures.

I just received a notice from the MA DOI, which states that they found no wrongdoing from the insurer. I also filed a complaint with the Department of Labor because my insurance is covered by the Employee Benefits Security Administration; I've been in touch with a rep there, but they have not provided me with any actionable information.

I would appreciate any and all suggestions considering (1) the insurers initial mistakes were not my fault and I had reason to believe they was initially correct and (2) I would have discontinued the procedure and not gone the 2nd or 3rd time had it been processed correctly the first time? I would appreciate any advice on where to go from here.

submitted by /u/Vegetable-Row-1448
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