Hospital sending claim for cpt code not provided on surgery estimate, surgery done, no pre authorization obtained please advise.

Hi there,

I had a left foot revision surgery for a neuroma and painful scar tissue for prior surgery on the bottom of the foot two weeks ago. I have anthem blue cross ppo through my job in CA(state job). Prior to my surgery, I asked my doctor if pre authorization was needed, and I was informed they checked and it was not needed. The hospital sent me an estimate for the hospital fee of $10,300 prior to the surgery and requested my 10 percent co-insurance. I paid the 10 percent on the day of the surgery. The cpt code provided on the estimate did not need prior authorization, I checked with my insurance company.

I called the hospital today to ask when they would send the claim to my insurance, since I noticed the anesthesiologist already sent their claim and it was processed already by anthem on my app. The hospital told me they were finalizing it and adding the final cpt codes. They told me they have 11 cpt codes adding to more than $25k that they would bill to the insurance for my surgery. I told them that my estimate did not have 11 cpt codes. They told me it was normal. I asked them about the cpt code listed on my estimate. I was informed they were using a different one for billing. They gave me on of the new codes they are using , Q4155, since my surgeon used an amniotic graft when closing the wound. I contacted my insurance, and this code needed pre authorization. Also it is usually medically necessary according to the insurance documentation in very specific cases.

I spoke to 5 people from the hospital billing today. This code by it self is more than $10k on the claim they will send to the insurance. They told me if the insurance deny it, they just will start and appeal for it. They said worst case scenario, I could get on a payment plan, but that I should not worry until the claim is processed. I asked them if they can use a different code. They said they will submit the request to their claims department, but it takes 45 days for review, and the current claim would be send to my insurance first.

I’m concerned because my insurance representative told me they will likely partially denied the claim with that code. All other codes could potentially get approved of medical necessity is proven. My insurance told me that once they receive the claim of denied for lacking pre authorization for that code, that they will let the hospital know the process to try to get retroactive authorization, but it does not guarantee they will get it. Hospital just tells me to don’t worry, if claim is denied, they will appeal, and if denied, they can discuss with me a payment plan. They are in network, I think this is unfair as this code was not even on the original estimate. Anything I can do? I spoke to 5 people from billing today. My doctor office said he did use the graft , but they did not submit a cpt code surgery request for the hospital to bill for it. However, doctor office said they are not responsible for how the hospital bills. Doctor is in network as well, I’m scared about getting a high bill due to hospital sending this cpt code and refusing to change it.