r/HealthInsurance • u/takenorinvalid • Jan 08 '25
Claims/Providers Anthem Insurance claims we're covered for a service as long as the provider is in-network but doesn't list a single provider as in-network
My wife has been waiting for a surgical operation, but my work through a curveball in it by switching our health care provider to Anthem.
Our benefits with Anthem explicitly state that this service is covered. The benefits section of their site also confirms it is covered with 30% coinsurance. But when her surgeon tried to put through authorization, they denied it saying that, even though the surgeon is in-network, they are a Tier 2 rather than Tier 1 in-network provider.
After hours of trying to fight that, I've started just using their Find Care tool to find any doctor anywhere in America that does this surgery that they'll cover and there is nobody. I have typed in every single zip code I can think of. I have called their customer support and made some poor lady spend 45 minutes trying to find someone, but there is literally no doctor on the entire planet that they will cover.
It's got to be illegal to claim that you cover a service and then refuse to cover every single doctor.
What options do I have?
UPDATE: I asked Anthem for a list of approved providers for the CPT code for our surgery and they sent me a list of therapists.
I think I've found the issue. It looks like the Anthem database for this CPT code has the wrong providers.
No idea how to proceed.
45
u/AnotherNoether Jan 08 '25
You’re right, they’re required to recover services that arent available in-network, and there’s a process for that. Ask about how to submit a “network gap exception” and then do that to get your surgeon covered. It might need to come through the provider rather than you, I’m not sure. It’s weird that you’d have to do this for tiered coverage
11
u/createusername101 Jan 10 '25
I like how we need to have lawyer level expertise in a system we don't have access to and didn't design in the first place to even have a fighting shot of getting the services we pay for.. it's getting ridiculous.
On a happier note, did everyone see medical debt is no longer counted against our credit scores?
16
u/takenorinvalid Jan 08 '25
The explanations for why our coverage was denied are probably meaningless. Every person we talk to seems to make up a different reason why, and none of them have made any sense.
18
u/takenorinvalid Jan 08 '25
UPDATE: I asked Anthem for a list of approved providers for the CPT code for our surgery and they sent me a list of therapists.
I think I've found the issue. It looks like the Anthem database for this CPT code has the wrong providers.
No idea how to proceed.
19
u/AlternativeZone5089 Jan 08 '25
Play dumb and pretend you don't know this and request network gap exception for surgeon you are already working with.
13
u/Janknitz Jan 08 '25
Could it be that the surgeon's office coded it incorrectly? You might call the surgeon's office and ask to speak to whomever submitted the request for authorization.
Meanwhile, request a copy of Anthem's "Evidence of Coverage" (EOC) for your plan. This is the actual contract between you and your insurer. You haven't seen it unless you specifically asked for it. The EOC may explain what to do if there is no in-network provider.
You can also talk to your HR department. They may be able to help.
I was working for a place once that got us dental insurance--we had to pay for it. It was a Dental HMO. There were providers in the area, but NONE were taking new patients. HR had to find a different plan.
6
u/AgentMonkey Jan 08 '25
Can I ask what the CPT code is?
-4
u/AlternativeZone5089 Jan 09 '25
It's the procedure code for what you're having done.
12
u/AgentMonkey Jan 09 '25
I know what a CPT code is. I was asking for the specific one for the procedure.
3
u/elevenstein Jan 08 '25
You have to get anthem to assist you with this. They are the only ones who can help. They need to provide a list of in-network providers and if they don't have any, they need to approve the surgery as in-network with an out-of network provider.
2
u/Vervain7 Jan 10 '25
What is the code the doctor gave? This doesn’t sound accurate. I am more inclined to believe the doctor is coding it wrong than anthem having a surgical CPT code aligned to therapist .
2
u/Certain-Yesterday232 Jan 11 '25
Anthem is likely wrong. I had a similar situation happen with Aetna. They had a mental health therapist coded as an acupuncturist. It took nearly a year and getting my HR involved to get them to fix it. I figured it out by going to their provider list, finding the provider and seeing they had "acupuncturist" listed for specialty. Yet they still had her listed in the mental health directory. 🙄
1
u/Easy_Ratio_5182 Jan 10 '25
Imaging that.. their database being incorrect. Yet they push us to these portals to find a provider and an estimated cost.
Seems like for anything it’s best to get a prior auth with expected costs.
And just because the doctor is in network doesn’t mean the ancillary services are.
13
u/AlternativeZone5089 Jan 08 '25
Request network gap exception. This is the kind of situation it is designed for.
4
Jan 09 '25
Came here to say this! Out of network override and the facility can either take the in network rate or negotiate
6
u/miritzi_sedai Jan 08 '25
So a lot of plans will have a provision to consider and out of network provider as an in network provider if there are no in Network providers in a given area (for example 50 mile radius). I would call your carrier and see if this provision exists in your plan. You can also have your provider request a single case agreement
7
u/Meffa63 Jan 08 '25
This falls under Network Adequacy. Many states have laws that require insurers to provide an “adequate network” of providers for every health service they cover. The law will set out the specific number of each provider type within a specific distance (miles or driving time) from where a member lives within the plan’s service area. If no such provider is available in the network, the member can see a non-network provider and get coverage at the in-network level (e.g., subject to in-network deductible & copay; no balance billing). This issue comes up a lot with behavioral health providers in particular.
1
u/evan938 Jan 09 '25
I'm fighting this in a sense getting OT for my hand/wrist post surgery. My surgeon, NP, surgery center, anesthesiologist, all covered under my Tier 1 benefits. Hand therapy, in same office as surgeon, NP...tier 2. BCBS has 2 tier 1 PT (not OT and not CHTs) within 25 miles. These are not hand therspists I need to be seeing. Their weasel way is saying "you have coverage under your tier 2 benefits"...yeah, after another $1k more deductible and 20% (vs 10% on T1) coinsurance costing me another $1500, so $2500 total, vs 0 on tier 1 which I maxed out already.
2
2
u/AlternativeZone5089 Jan 08 '25
Single case agreement is the same thing as a network gap exception OP.
6
u/temerairevm Jan 09 '25
This is worth a call to your state department of insurance. It would depend on state regulations but I think there’s a good chance they could help you and working with them will make the insurer more cooperative.
3
u/pangea_lox Jan 09 '25
Insurance companies should be held responsible for their online provider listings. Good that you called.
3
u/sanityjanity Jan 10 '25
Oh hey, I had this exact same problem with UHC, that company that is being sued for using an AI to deny claims.
UHC's website wouldn't give me any providers that took their insurance within 30 miles of me, in spite of the fact that there are dozens of hospitals and medical centers close to me.
Also, when I was searching for a gynecologist, it would only give me gynecological oncologists (obviously a different thing)
So, I called them, and the person on the phone gave me a list of 10 providers. Except that five of the entries were all the same doctor, but just at five different locations. And that doctor had left all those practices.
FINALLY, I got one referral to one doctor at a large medical center. I called the medical center (nearly in tears) to ask for help, and they pointed out that, if they would cover one doctor there, they would cover ALL of them. So, the medical center helped me to find a doctor who would take my insurance.
So, I would recommend that you
call the insurance company on the phone to get referrals (you may get different ones)
call your local medical centers, and ask their billing departments if they take your insurance
call your HR department, and tell them what is going on, and ask them to help you escalate this problem. SOMEONE in the insurance company can fix this, but they aren't going to do it for you. You are not the customer. Your employer is.
Then, in the long run, we need a class action lawsuit. Because these corporations are actively trying to kill us, and they're succeeding every day.
3
u/sanityjanity Jan 10 '25
When you call the insurance company, you need to just keep asking for names, case numbers, and asking to escalate.
"I understand, Stella, that you can't help me with this problem. Can you please tell me the case number for my complaint? Great, now, can you please escalate me to the next tier. I need to talk to someone who can help me."
2
u/Winnie1916 Jan 10 '25
My work colleague had an issue with coverage. He talked to HR and they gave him the name and number of a specific person at the insurance that was tasked with resolving issues. He called and 3 days later issue was resolved. Try calling HR and see if there is a similar person for your workplace.
2
u/corgicrazy1971 Jan 11 '25
Call their Utilization Management dept. for a network exception. I just went through this. Surgeon is covered in network but not the practice. There were no other covered surgeons within 100 miles. Doctor can fill out the form and an Anthem medical professional will review the case. Took 3 months and a few back and forth calls between Anthem, me, and doctor's office.
1
u/No_Calligrapher9234 Jan 09 '25
GET SOMEONE at the insurer to resolve this issue immediately WTH why are we figuring out their errors?? !!
1
u/theory_of_me Jan 10 '25
Do you have a benefit advocate at work? They can likely escalate this quicker. I had an issue with Cigna billing and my work got it escalated to a “platinum services specialist” who had to navigate Cigna internal processes to fix it.
1
1
u/cphil32 Mar 21 '25
Hey, I used to work for Elevance before they RIFd me in July. I worked for a state specific health plan, but if you send me a chat with your state and plan name, I might be able to point you in the right direction/department there to actually get this straight.
1
u/noticethinkingdoggos Mar 22 '25
Depending on your state and healthplan, local laws may prohibit their retroactive denial of the authorization. Also, it might fall under the 'surprise' medical bill laws that some states have, which may also offer protection, like this for NY: https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills
•
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