Insurance verbal pre-approval withdrawn after sleep study causes big bill – any options?

Greetings –

I am looking for some advice regarding unexpected bills from my PCP clinic after a sleep study. I have been a regular patient there for nearly 30 years but have had some recent insurance changes, most recently and prior to the events here, switching to United HC's Student Resources Plan (grad student here).

The long-story-short is that I asked for confirmation before, during, and sometimes after every appointment about insurance coverage, received assurances that specific appointments were covered, and then got a massive bill weeks later. I don't know if I have any options other than to just pay what they're asking, after a coding adjustment that reduced it by ~50%. I have written a timeline below to help me get things straight and hopefully tell a complete story without letting my feelings of frustration and being lied to seep through.

Timeline:

I call and schedule consultation appointment prior to take-home apnea test. I inquire about insurance pre-approval; staff confirms that appointment will be a standard co-pay of $35 for a "specialist."

Visit 1: Discuss apnea testing with nurse and PA. They think testing will be covered by insurance. I ask them to confirm with their billing staff member, "Mary". It is not covered and will cost $500 for the test and the doctor's analysis, and the follow-up with the PA will cost $35 again. I agree to pay the $500 out of pocket. I pay $35 for this first appointment before exiting.

[Note: at some point, cannot remember if before or after first visit, I speak directly with Mary and she confirms the appointments are covered but the sleep study is not.]

Visit 2: I pick up the testing device and pay $500.

Visit 3: I return the testing device.

Clinic calls to schedule follow-up to review test results. They verbally confirm that the follow-up appointment will be the $35 specialist co-pay.

Visit 4: I discuss test results with the PA, who recommends apnea MAD device and writes referral. I am told a device would likely be covered by insurance but they cannot confirm. I am not asked to pay $35 upon exiting, and am told it will appear in the online patient portal.

I contact my dentist for the MAD. They do not file medical insurance, so I contact insurance directly. They cannot seem to understand what the MAD is, but tell me no sleep disorder treatment is covered. I cancel all of my appointments with the dentist.

Three weeks later: I receive a notification from the clinic portal stating I owe ~$1700 for the consultation and follow-up appointments.

After calming down, I contact the clinic and talk to Mary. She expresses surprise and tells me she will do what she can. Two days later, the first visit is "down-coded" and the follow-up (Visit 4) is left as-is, with a net price tag of about $900.

It seems to me that they never confirmed with my insurance that the specialist visits were covered, but told me they would be based on some assumptions I am not privy to. In retrospect, I perhaps should have been suspicious when I found out the sleep study was not covered. Instead, that made me think they were actually confirming that the PA visits were covered. I spoke with Mary today and her story is that they did contact insurance and the rep said it would be covered, "even if it is a sleep disorder diagnosis," but the official line change after they actually filed the claim.

The only recourse the clinic has offered point is a 9-month payment plan and 20% discount if I pay in full. I can afford the bill in full (sort of), but of course do not want to pay it, nor think I should need to after taking every precaution to be sure I was playing by the rules of the insurance game. It is hard to stomach when that money could have nearly paid for the apnea device out-of-pocket, and now I will have neither.

Do I have any options here? I could contact insurance but all I have a is he-said-she-said story.

Thank you for your time reading this lengthy post, and for any ideas you can send my way.

submitted by /u/Alaskensis
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