Nefarious Behavior?

I got married 10/30/22 and joined my wife’s health insurance effective that day. The plan was called United Healthcare Choice Plus, and a major reason I wanted to get on her health insurance is because I have a rare neurological condition called Superior Canal Dehiscence Syndrome which essentially requires inner ear/brain surgery. I’ve been seeing doctors at UCLA where I live in Los Angeles for the last year because not only are they fantastic, but they’re in network on my wife’s plan. I had my brain surgery scheduled back on 3/15/23 and saw the second surgeon on 4/26/23. (Two surgeons will be performing this procedure) – I went into my Pre-Op doctors appointment recently on 7/20/23. Afterwards, I saw something on United Healthcare’s portal about this doctor being out of network, but I thought to myself, that couldn’t be, I verified that all my doctors and surgeons were in network months ago. Well, here’s where the “This is America” song starts. Apparently after hours on the phone and doing a whole bunch of research myself, I found out that United Healthcare changed the policy and did not notify a single person. Not only did they not notify the benefit’s administrator, Gusto (based in San Francisco), but they apparently didn’t seem to notify a single person in my wife’s company. I have verified with Gusto that my wife’s employer chose the same health plans in 2020, 2021, 2022 with nothing to be changed. From what I’m to understand, is that United Healthcare changed the policy all the way back on 8/1/22, but the changes would not implement until each employee’s deductible reset per their hire date. My wife’s hire date was 6/1/21 which means that on 6/1/23, the deductible reset (which was my intention, as I wanted to pay into it as it reset, so the insurance would kick in after the $7500 deductible I would easily meet with brain surgery, labs, scans, etc.) However, when it reset on 6/1/23, it also changed my wife’s policy from United Healthcare Choice Plus to United Healthcare Core Network. There was no correspondence about this change. Not only that, but I was able to go to pre-op authorization appointment on 7/20/23 for the surgery (scheduled 8/11/23 ((which has inevitably been pushed back)) without any troubles. They didn’t seem to even recognize my policy had changed in the office. I called United Healthcare later that day because I received a letter in the mail claiming one of my CT’s for my brain mapping was denied because I was out of network. This didn’t make any sense to me, but that’s because I wouldn’t know, no one from United Healthcare’s Group Services sent correspondence to Gusto, the benefit’s administrator, that a policy change was coming down the line. I contacted Gusto over the week and they confirmed with me that they have absolutely zero correspondence from United Healthcare that a policy change was going to take place in the last 2 calendar years. I have spent several hours on the phone with supervisors from United Healthcare that cannot confirm or deny any correspondence was sent to the benefits administrator. The benefits administrator, Gusto, seems to be scared of me every time I contact them asking what recourse is for a health insurance company failing to notify them about a policy change. They keep telling me they need to dig deeper and they’ll be in contact with me, but I’ve found myself in the Spider-Man meme with UHC & Gusto simply pointing fingers at each other without any digging. So, as of 6/1/23, my surgeons and doctors at UCLA are now out of network overnight and the financial clearance administrator at UCLA has been helping me fill out Continuity of Care forms and OTA forms as well to have the surgery approved under a one time exception given that I in fact WAS under these surgeons care as well as in network all the way up until 6/1/23. My wife’s boss is livid and mortified by this experience, as I can tell he prides himself on being exceptionally professional and has written a few scathing emails to UHC and Gusto claiming that UHC is engaging in nefarious behavior given that I was not only never notified that doctors and surgeons would be out of network, but that I had to spend 3 hours on the phone just to find out that these change’s implemented, and even they had a hard time understanding what happened because they saw the previous claims with these same surgeons as in network prior to 6/1/23.

So, what can I do? Not only have I spent 3 years with this awful condition, but I’ve spent 1.5 years of that getting it properly diagnosed and making sure I get the correct procedure as 90% of general practitioners have never even heard of this neurological disorder. I can’t even tell you how many times I’ve sat in an ENT’s office while they literally Google Superior Canal Dehiscence Syndrome in front of me and then recommend something like a myringotamy, which would absolutely not fix my issues and would undoubtedly make my life a living hell.

So, any advice on what more I can do? This does all seem slightly nefarious as my wife’s boss described, because there is absolutely zero correspondence about these policy changes. Not a letter, an email, a phone conversation, nothing. United Healthcare effectively changed the policy overnight on 6/1/23, and now every doctor in the UCLA network is out of network and I had the pleasure of finding all this out less than 30 days from my brain surgery (8/11/23) that was scheduled back on 3/15/23 while I was in network.

Not only does this seem like an egregious oversight, but it feels extremely negligent. I believe Gusto and that they never received correspondence, but between Gusto and UHC, it appears their only defense is to point the finger at each other until I get tired of accusing each party of negligent or borderline nefarious behavior.

Any advice is appreciated.