Please help Pre authorization denied, hours before surgery, my foot is still broken. What are my options?

Hi and thanks for reading..

I fell and fractured my ankle, bi malleolar fracture. My insurance is UMR however It is managed by "accolade" and I can only speak to the accolade team.

I was scheduled for surgery today, with a surgeon I trust, and already have given ~2000 advance to the hospital and ~200 advance for doctor. A couple of hours before procedure I get a call from insurer saying that pre authorization claim was denied, so I had to delay surgery one more week , as I didn't want to risk paying back six figures for a few years.

Insurer cited reasons for denial:

Missing information, need to know about loose fragments, abnormal separation of the joints, any displacement gaps

When I talked to the doctor's surgery coordinator, 'Danny' she said that a) she's dealing with a new insurance she's never dealt before, ( my guess is she's referring to accolade ) they are 'picky' and she sent the images which clearly show those gaps and separations.

My insurer called Danny providing instructions on how to appeal the denial , if I remember correctly by sending a fax with the missing information.

Had a call with Danny, told me that she submitted the claim, however she was not sure when or if it would be approved.

I spoke to the insurer a couple of times and got mixed information on what to expect next:

One agent said that the appeal would be answered within 48 hours.

Another person told me that appeals have a 45 day wait time, which drove me crazy ( I am not willing to wait 45 days with a broken foot).

Another option I was given is to ask the doctor to call a number and schedule a peer review , which would lead to a fast approval time.

I feel very very lost, and I'm not sure who's in the wrong or if Danny is doing as best as she could.

I FEAR for my appeal to take too long to be approved, or even worse, I fear the appeal to be denied due to lack of information(again) , I am not sure if I can trust the surgery coordinator 'Danny' any more.

Would it be a good option to directly talk to the doctor and ask him to call my insurance to request for a peer review?

Should I go to another doctor and ask about the time it takes for pre authorization, and forget about the current doctor?

What are my rights regarding the money I already gave them, how likely is to get a refund if I were to go with another doctor????

What is the likelihood of my appeal to have been denied?

Please help I'm so new to all this insurance bureaucracy

submitted by /u/jorgeisaacchacon
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