(New Mexico, US) Bait and Switch? Health Insurance Company Approved and Paid for My Wifes Surgery, Then Took the Money Back

Early last year, my wife had an ACL replacement and meniscus repair surgery on her knee. She had been suffering from a torn ACL for several years, and her meniscus tore in a couple of places, necessitating the surgery.

Before the surgery, she had two healthcare plans: one from United through her work and one through the marketplace TrueHealthNM. She designated TrueHealth as her primary insurer because United would not cover the hospital where her doctor worked. TrueHealth was initially her primary insurer through her work, but when her employer changed health plans to United, she had to get a new plan through TrueHealth on the marketplace for continuity of care with her existing doctor.

We made sure to confirm our insurance coverage before the surgery. TrueHealth was designated as the primary insurer, and United was the secondary insurer. After the surgery, my wife did a few months of physical therapy, which was also covered and paid for by TrueHealth as primary and United as secondary.

However, at the start of the new year, we received a surprise bill for physical therapy that stated that no insurance covered the cost. The explanation of benefits indicated that we needed to do another coordination of benefits. We did one, and TrueHealth stated that they were not my wife’s primary insurer during 2022; United was. United, on the other hand, claimed that they were not my wife’s primary insurer in 2022.

TrueHealth now refuses to pay anything, even as a secondary insurer, because United hasn’t been billed as primary first. They claim that they spoke to my wife in 2022 and told her that United was her primary insurer, but this conversation never happened. If we had been told this, we would not have gone through with the surgery at that hospital.

To make matters worse, TrueHealth is now doing a recoup, and we are getting bills from the hospital for the entirety of the surgery ($89k) and for the pre-surgery MRIs and post-surgery physical therapy, all of which had already been paid by TrueHealth.

We are now in danger of being sent to collections with massive bills by the hospital. We’re not sure where to go with this, and our next step is unfortunately a lawyer’s office, which we can’t afford. Any advice would be greatly appreciated.