Need advice for insurance denied claim due to hospital failed to submit Prior Authorization
I went to a sleep study by a referral form my PCP where the hospital is in the network (both PCP and Sleep Lab are in the same hospital). I checked with my PCP and sleep lab if it was covered and if PA was needed. Both of them said there was no need for PA for my case and fully covered. However, when I called insurance they said they needed PA for a sleep study then it would be fully covered. Then I called back to Sleep Lab to tell them that. However, the sleep lab confirmed to me that there is no need for PA. So I believed the sleep lab (I know that I made a big mistake).
However, I got the EOB from insurance that they didn't cover sleep study due to missing the PA. The EOB is around 8k.
I called the sleep lab (almost 2months ago) for them to help me with the problem. The sleep lab supervisor said it was their error and would fix it for me. So the supervisor (sleep lab) sent the initial retro authorization, which was voided due to an incomplete form. Then, the supervisor (sleep lab) sent the second retro authorization which was denied because the provider failed to submit the prior authorization. I called the sleep lab supervisor for the result and she said that she couldn't help me anymore and pushed me to talk to the billing.
I called insurance they said that the bill would be sent back to the hospital and I could do an appeal regarding this issue.
I called the billing regarding regarding the bill, they said there wasn't any bill posted on my account yet.
Recently, I went to see my PCP(last week) and explained what happened. She said that the hospital system showed no need for PA for sleep study. She wrote the letter to insurance with the screenshot that the hospital system showed no PA needed. However, the insurance still denied the claim and she told me that was the best she could do.
As my last resort, I called the patient advocate(this Monday) and explained the situation. The patient advocate filed the grievance and paused the bills. The representative said would be about 2 months to know the result.
My questions are …
Will I be responsible for paying the full amount of the bill in this case?
What should I do if the appeal and the grievance don't go well?
Could you give me any advice on what should I do next?
I have a CareSource Marketplace, housewife(f26, no income), Ohio.
I have been waiting almost 2 months since I talked with the sleep lab supervisor. I am so stressed and very anxious about the bills.
What I learned from this is everything needed to be documented and believed in insurance.
Thank you for all your advice.
submitted by /u/Tomyam_seafood2828
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