Out of network reimbursement with network inadequacy approval but charges in excess of allowable amount
Hi, I have a bit of a complicated situation where I am trying to figure out the best way to move forward.
I payed out of pocket for a service and am now looking for reimbursement from my insurance companies.
I have two health insurance plans, and both (through a long and arduous process) granted an exception for me to receive service at an out of network provider because their networks were not robust enough to provide the service. Through Aetna, my primary insurance, my filing was called a network inadequacy request. Through my secondary, United Healthcare, this was called a GAP exception.
My primary insurance reimbursed me for 90% of the out-of-network or uninsured price up to the amount for the CPT code in my zip code on fairhealthconsumer.org which was thankfully the majority of the amount, but left me with about $2000 out of pocket. When sent to my secondary insurance, they deferred to the allowable rate by my primary insurance, and so only paid the 10% remaining of the price on fairhealthconsumer.org, leaving me still with the $1500 excess of what was considered "reasonable and customary" to my primary insurance.
I am trying to figure out my best strategy for working with the 2 companies to get the full amount paid. Here are some things I've thought of trying:
1) argue that my primary insurance should cover this up to charge, not up to the fairhealthconsumer.org amount, since there was not a cheaper option for identical care available in my zip code
2) try to argue with my secondary insurance that they should cover that remaining $1500 and not defer to my primary insurance's allowable amount. After all, they paid less than $500 for a major medical procedure
3) Get a corrected claim for my provider that includes more CPT codes and not just a global code, since they had me include 4 cpt codes on my inadequacy request and only put one of these cpt codes on my bill.
Any thoughts? After a lot or review it doesn't seem like the way either company processed the claim is necessarily wrong, however it does seem unfair and I want to try to get the remaining money if possible.
submitted by /u/scopalhair
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