In-Network Provider Didn’t Get Pre-Certification, PLEASE HELP

I’ve seen an in-network ophthalmologist four times for IPL treatments for dry eyes since December, 2022. My appointments were on 12/7, 12/21, 1/4, and 1/19. I had met my annual out-of-pocket maximum on my health insurance plan through Cigna well before the December appointments, but the provider requires up-front payment regardless. I paid $395.00 per treatment, and they agreed to bill my insurance company. They said that before reimbursing me, they would have to see a “pattern” of Cigna paying for the treatments, therefore they wouldn’t simply reimburse me for the first treatment upon receiving payment for it, they would require reimbursement from Cigna for all four treatments before they would reimburse me for any of them. This seemed unusual and suspicious, but I really needed the treatments, so I agreed. I also signed a form saying that in the event that my insurance company didn’t pay for the treatments, I understood that I would be financially responsible (even though I was paying up front); this became relevant later.

On 12/27 I called Cigna about another issue and asked about this provider’s billing practices during the call. The representative told me that the provider had failed to obtain the required pre-certification for the 12/7 treatment, that I wouldn’t be penalized for that, and that the provider would have to obtain it retroactively.

On 1/4 while waiting in the lobby for my third treatment, I noticed that the claim for my first treatment on 12/7 had been paid, but that the claim for my second treatment on 12/21 had been denied by Cigna due to no pre-certification. The EOB noted that I did not owe any payment to the provider myself due to the provider’s contract with Cigna. I mentioned this to the assistant when I was called back to the exam room; she told me that the pre-certification is something Cigna does, not the provider. This made no sense to me. I’m somewhat familiar with pre-certifications in genera, and I know they’re essentially pre-approval for a service and the insurance company agreeing to pay for it. Obviously Cigna wouldn’t self-seek a pre-certification with Cigna for a procedure they don’t even know I’m having done. I figured it would eventually get sorted out and let it go.

While waiting in the lobby for my fourth service on 1/19, I checked the Cigna app again and saw that the claim for my second service on 12/21 still showed denied due to no pre-certification and that the claim for my third appointment on 1/4 also showed denied for the same reason. I again asked about this when I was called back to the exam room. The same assistant who had told me on 1/4 that the pre-certification is something Cigna does then told me she really didn’t know anything about pre-certifications and that I would need to speak with the front desk. When checking out that day, I brought the issue to the attention of the front desk staff. The person I spoke with said that I would need to speak with the clinic’s billing office in another city and not to worry because they would continue to resubmit the claims until Cigna pays them.

On 1/24, I called Cigna about the issue and was told that the claims were indeed denied because the provider failed to obtain the required pre-certifications and that it’s now TOO LATE for them to obtain retroactive pre-certifications for my 12/21 and 1/4 treatments, as they only have 10 business days after the service to do that. I asked if Cigna could insist that the provider reimburse me the $395 per treatment I had paid for the 12/7 appointment, as Cigna has already paid that claim, and the 12/21 and 1/4 appointments, as the provider is in-network, and the EOBs for those dates (and the 12/7 service) show a $0 patient responsibility. The Cigna representative declined, saying that any pre-payment is between the patient and the provider, and suggested that I file a complaint against the provider with Cigna.

After speaking with Cigna, I called the provider’s billing office. The representative there told me that Cigna is known to require pre-certifications for IPL. I asked, in that case, why the provider’s office isn’t automatically doing pre-certifications for every Cigna patient. The billing representative said, “If the patient doesn’t bring it to our attention, we may not always do it.” This seemed ridiculous, since it’s their responsibility as an in-network provider to know the insurance company’s requirements, not the patient’s responsibility to tell them, and also because I DID bring it to their attention twice and was essentially brushed off. Had the provider’s staff actually paid attention to me when I brought up the denials due to no pre-certifications on 1/4 and 1/19, they could have obtained retroactive pre-certifications for the 12/21 and 1/4 services within the allotted 10 business days and obtained the pre-certification for the 1/19 service ahead of time like they’re supposed to. She then went on to remind me of the form I signed stating that I understood that if my insurance company didn’t pay, I would be financially responsible. This would be reasonable to me in the event, for example, that IPL was not a covered service under my plan, but Cigna has confirmed that it IS a covered service if the provider obtains the required pre-certification. To be held responsible for $1,600 that my insurance company would have covered because the provider’s staff failed to do their jobs feels incredibly inappropriate. The billing representative also said that a pre-certification for my 12/7 appointment was never obtained even though Cigna did pay that claim. As such, she believes that when Cigna reviews my account, they will retract that payment, and she is therefore declining to reimburse me for that service despite the fact that Cigna has paid the claim. (The provider is also not honoring the contracted rate for the IPL treatments even though they’re in-network, as the contracted rate is approximately $260 per service, yet I have been charged $395 each time.) The billing representative said she would reach out to the clinic manager the following day (1/25) to inquire about having them do a retroactive pre-certification for my 1/19 treatment and find out why they weren’t getting the pre-certifications all along. I followed up with her on 1/25 to ask about the status of that, and she said that she’d emailed the clinic staff but had not received a reply, so it seems they’re ignoring her just as they ignored me.

I’m at a complete loss as to what to do here. It’s unbelievable to me that Cigna can’t step in and help, and that the provider is allowed to require up-front payment, willfully drop the ball on the required pre-certifications, then essentially say oops, sorry, you’re still responsible for the $1,600. The billing representative said that she can and will appeal the claim denials, and Cigna also told me that that’s an option, but there’s no guarantee that the denials will be overturned. At best, I’m apparently looking at months of waiting to get the reimbursements; at worst, I may be out $1,600. Is there anything else I can do? I’ve considered explaining all of this to my bank and disputing the charges, but I know the provider’s office will simply send the bank the forms I signed saying I understood I would be financially responsible if my insurance company didn’t pay. Would the EOBs showing $0 patient responsibility help in that case? I feel like even if the bank ultimately sided with me and refunded my money, the provider would probably then refuse to see me going forward. I don’t prefer to continue to get care at a place that clearly doesn’t know what they’re doing with regard to insurance and billing and takes such an apathetic approach to real-life, expensive consequences to patients for their incompetence, but this is the only place in my area that offers this treatment (it was invented by the doctor I’m seeing), and it’s helped my condition a lot.

TL;DR: An in-network provider’s staff failed to obtain required pre-certifications for four IPL treatments I received. As a result, my insurance company denied the claims. The provider required up-front payment from me and is now refusing to reimburse the $1,600 I paid for the treatments even though they are a covered service under my plan, provided that the required pre-certifications are obtained, and even though my EOBs show a patient responsibility of $0 for each treatment.