The provider did treatment even though Insurance denied Pre Auth (USA)

Hope you all are doing well. We are based in California, USA. My wife has been undergoing active cancer treatment since Jun'22 and we have never had any issues pertaining to her health coverage from the provider or insurance for receiving standard treatment. As I understand, the provider submits a prior authorization to the insurance. Once the prior auth is approved, we go ahead with the scheduling. This system has worked well with our Medical Oncology and Surgery teams.

However, it seems our radiation team submitted the prior auth for 4 weeks of XRT + 1 week of boost in Jan'23. Apparently, the prior auth for 1 week of boost was denied. Our provider never flagged this. My wife went for her radiation appointments as scheduled in March'23.

Now, even though my wife has met her out-of-pocket maximum, the provider's bill has an outstanding balance. The provider billing department says STILL we need to pay for the boost treatment (~$1000) as insurance denied it. Insurance says they informed the provider about the denial back in Jan'23 but the provider still went ahead and did the treatment and hence they denied it.

We were hoping for your thoughts as to what should be our next steps. My wife thinks as we already reached our out-of-pocket maximum and as she received standard treatment we shouldn't be paying for this. Thank you in advance for your time and suggestions.

Age: 37, zipcode:92122, Income: $95k yearly

submitted by /u/emptydesignmill
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