r/HealthInsurance • u/Tough_Cauliflower767 • Apr 11 '25
Claims/Providers 96k bill not covered
My wife and I are seeing a fertility doctor. The MD was adamant my wife needed surgery to clean out the fibroids and polyps in her uterus to improve conception. Prior to surgery, i confirmed over the phone that this was covered by my insurance. The fertility clinic said it's covered beside a $400 anesthiesia fee and good to go. Post surgery I got a bill for $3500 because apparently not everytning was covered. I reached out to the clinic and they don't know why it was denied. I sent an appeal to bluecross after that. Just got a notice in the mail that the appeal was denied and we owe 96k!?!?
It's after hours but I will follow up with them tomorrow. Praying this is a mistake. I feel like this is a he said she said with the insurance coverage. How can they tell me it's covered and then send me bills. Am I liable. Who os at fault.
Thank you
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u/chickenmcdiddle Moderator Apr 11 '25
Start with the documents produced by your insurer—have you received an EOB (explanation of benefits) from them yet? It details the claim(s) submitted by your care provider and if it’s denied, will have reasons listed.
If you don’t have a copy of the EOB, log on to your insurance portal and take a look for a digital copy. Then, upload a copy here with your name / address / other sensitive date blurred or blocked out. This will contain key information regarding why things were denied and what your liabilities are.
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u/Tough_Cauliflower767 Apr 11 '25
Thank you so much. I will follow up tomorrow
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u/Local_Historian8805 Apr 11 '25 edited Apr 11 '25
I have heard stories of patients getting bills for open heart surgery when they had a different
operaoperation, so please review the eob before you pay anythingEdit. Fixed auto cucumber’s shirt
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u/Tough_Cauliflower767 Apr 11 '25
Thank you. I will.
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u/ShotCode8911 Apr 16 '25
Just a heads up, if you ever get a bill for insurance, always check the billing codes against your EOB. Medical billing code errors happen like over 50% of the time.
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u/Aspen9999 Apr 12 '25
Your Dr saying it’s covered doesn’t mean it is. Also, even in general, unless there’s a medical issue( fertility or lower fertility isn’t a medical issue really) for the surgery these types are never covered.
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u/ih8saltyswoledier Apr 11 '25
Your insurance likely has an infertility exclusion and your clinic billed it with infertility coding. It may be worth talking to your clinic and seeing if they can resubmit to insurance with different coding - possibly a gynecological code rather than infertility related?
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u/MoonbeamPixies Apr 12 '25
Yeah, fibroids should still be covered aside from fertility issues. Im sure there have been other symptoms besides the infertility
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u/Dancelifeaway Apr 11 '25
$96k is kinda high! My polyectomy/hysteroscopy was $25k. Double check and make sure they put the correct billing codes. Covered doesn’t mean it’ll be fully paid for. Has she met her OOP max?
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u/AlternativeAthlete99 Apr 11 '25
it depends if the fibroids were able to be removed via hysteroscopy, some need to be removed laparoscopically, which would increase the cost of the bill. $96k is a lot, but mine was $76k because it required laparoscopic removal of some of the fibroids
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u/Dancelifeaway Apr 11 '25
Mine was everything polyectomy/hystero, and lap. Luckily I paid nothing cuz I met my OOP already. That’s insane! Gotta love USA healthcare…
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u/AlternativeAthlete99 Apr 11 '25
I thankfully had met my OOP max as well, so Ig was nothing, but i was shocked when I saw the overall bill if insurance didn’t pay anything
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u/MoonbeamPixies Apr 12 '25
God even the out of pocket max should have long been met before the 96k, thats a ridiculous amount
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u/ktappe Apr 11 '25
You say you “confirmed over the phone” that you were covered. But you don’t say who you were calling. Was it the doctors office or insurance? If it was the doctors office, you have a problem. You needed to call insurance.
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u/Tough_Cauliflower767 Apr 11 '25
Yes. I called the fertility clinic who was performing the surgery. They confirmed i was good to go minus the anesthesia fee. I wonder if the clinic did not run a pre authorization first and assumed I was covered. Blue cross denied my appeal so far after I explained the situation.
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u/AlDef Apr 11 '25
The provider doesn’t know what your insurance does and does not cover.
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u/Tough_Cauliflower767 Apr 11 '25
I assume the process is to run a pre authorization to see what is covered. Doesn't the provider need to make the patient aware how much they will owe out of pocket if they choose to carry out the surgery? Either way, why would they tell me I'm fully covered if they didn't actually know the answer to that?
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u/HelpfulMaybeMama Apr 11 '25
"Fully covered" doesn't mean 100% paid by insurance. It's like "full coverage" on auto insurance. That's not an insurance term. You'll never find it in a policy document. But people use it, and if you ask 10 people what it means, you'll get 8 or 9 different responses. None of them match up to an insurance policy (the contract).
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u/WadsRN Apr 15 '25
Ultimately, it’s your responsibility to check with your insurance company about what is covered.
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u/HelpfulMaybeMama Apr 15 '25
100%. And most people ask the provider, assume it's covered (at 100%, of course), or don't ask at all until they receive the bill.
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u/Tough_Cauliflower767 Apr 11 '25
That's misleading. Especially when they say all I will be responsible for is the $400 anesthesia fee
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u/HelpfulMaybeMama Apr 11 '25
I don't disagree with you. Unfortunately, they can not speak for the insurance company. Always, Always, Always refers to your summary of benefits that your employer or carrier provided during ipen enrollment. It spells out what your carrier will pay and won't pay for, and how much is covered. Or contact the carrier. But the provider is never going to be the best source of coverage information unless they reach out to the carrier and received something in writing because the carrier can only cover what their contract says, and at the rates listed.
But share EOB information.
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u/Junior_Season_6107 Apr 11 '25
The insurance company can’t even speak for the insurance company. I always love the prerecorded messages before I reach a person that pretty much says that whatever they say isn’t guaranteed. 🙄
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u/dlc9779 Apr 11 '25
Lol, the Dr office has no idea how your insurance will pay. Even if they accept your insurance. Because there is so many reasons why this may not have been medically necessary. Especially since the reasons they performed the procedure was for fertilization and not a medicalthreat. It seems like an elective procedure. You probably are on the hook for most of this. Never listen to the Dr office. They only get paid if they performed the surgery. So yeah, they are more likely to lie without verifying if it's actually covered. Good luck.
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u/positivelycat Apr 11 '25
Or they called insurance and was told no auth needed.
Of course knowing that is only useful if insurance denial is no prior autg.
Next time call your insurance.
Also find out the digonstic code on this claim, is the primary infertility, if so ask for a coding review to see if a different code can be primary
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u/HelpfulMaybeMama Apr 11 '25
"Covered" doesn't tell you how much the carrier will cover. There are thousands of plans, and the only way to determine how much is covered is to request a preauthorization and get it in writing. That doesn't tell it is deemed to be medically necessary (usually a requirement for coverage), but it tells if you medically necessary, how much/what will be covered.
Your provider doesn't know until they provide treatment plans and billing codes to the carrier. They aren't doing that in a quick phone call.
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u/jx1854 Apr 11 '25
Unfortunately, its your responsibility to check with your insurance company. Its not the providers role. You cant trust what they say. Its also not legally binding.
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u/catsmom63 Apr 11 '25
Coverage for fertility issues would be outlined in your policy.
I’d check online for coverage, and then call to discuss.
As someone who worked in insurance ( not health insurance) never ever take a doctors word for whether something is covered or not.
They ( your doctor) would not know in most cases, you need to refer to your health insurance policy contract which should be online.
My sis suffered infertility (Endo) and went through multiple rounds of IVF to no avail. Luckily her hubby’s policy was the best of the best insurance wise and covered everything.
Not all insurance carriers will cover infertility issues or surgeries related to them.
You will need to speak to BlueCross to get your answers.
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u/chefbsba Apr 11 '25
You need to look into your plan documents to see what your coverage is for fertility issues/treatments. Many plans won't cover anything related to this because it is not medically necessary to get pregnant.
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u/Dry_Studio_2114 Apr 11 '25
Appeals Manager -- OP, what was the rationale the insurance carrier provided to you in the appeal response letter for upholding denial?
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u/HelpfulMaybeMama Apr 11 '25
What is the denial reason on the EOB? Is the provider in network? What is your deductible, copay/coinsurance, and max out or pocket?
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u/madisongirl_2z917 Apr 11 '25 edited Apr 11 '25
I don't know who said it on here, but you always always have to call insurance for a quote of service. The provider will definitely not be able to give you an accurate quote because every insurance policy is different. This happened to me, I was going in for a procedure one clinic was saying it'll cost over $4k. I called my insurance and they said if I go to a different clinic up the road from me it will only be $600. That's a huge difference. But the doctor ordering the procedure had no clue about that. That being said, you should keep appealing. Just keep appealing and do it with your state board if you have to. Every bill should have a document that states the places you can appeal on the very last page (people usually don't read that far). Just keep fighting it. I work for one of the big insurance companies and this is what they don't tell you, you can always fight your denial. I once fought a couple thousand dollar hospital bill stating financial hardship. It was a huge pain but in the end the hospital wiped my whole bill. The mistake people make is they usually give up, letting the bill go to collections. Just don't give up, you got to be persistent. State financial hardship, appeal, do whatever you have to just don't let it go to collections. Remember, it's a scam anyway. Health care is a human right and should be free for all.
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u/AnonymousGirl911 Apr 11 '25 edited Apr 11 '25
Always always always record phone conversations with your insurance company. They record you, but they sure as hell aren't going to use said recording to prove YOU right.
Some states have "two-party consent" laws, meaning both parties must agree to being recorded. You agree when you call your insurance because there is always the automated "this call may be recorded for quality and training purposes".
As soon as you get on the phone, start that recording. When you get on the phone with an agent you inform them that you are recording the conversation just as they also are recording. Get their name, if they have an ID number get that too, and the department they work for.
I always do this and it helped me when they tried to fuck me over one time. I said "that's interesting because I have this recording where I spoke with [insert name, id number, and department] on [insert exact date and time] and they said [exact verbatim statement]."
All of a sudden they said "😃 oh yeah now I see your plan covers that!"
🤔 interesting how you "figured it out" once you realized you got caught
Also, get things in writing. Ask for both the insurance company and the clinic to give verification of what your out-of-pocket cost will be and what the insurance will cover.
If all else fails after doing all that, threaten with legal action. Get a lawyer and send them a scary legal letter with all your documentation.
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u/LizzieMac123 Moderator Apr 11 '25
While this is a solid option if you do have proof of insuramce stating benefits are covered... but OP didn't call insurance to verify coverage- they asked the fertility clinic. Never trust what a provider says is covered, they are not looking at every single policy they are in network for. Most they see is deductible, oopm, and coinsurance amount. Even with a Prior authorization, a PA approval doesn't mean insurance will cover any portion of the care, it just means you meet the clinical criteria upon initial review and that they will pay in accordance to your plan details... but the plan details could state that coverage isn't part of your plan.
OP should check their contract and make sure fertility coverage isn't listed in the exclusions clause as it is often excluded. Most plans only allow one to get tested for infertility but don't cover much once you find out how fertile/infertile you are.
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u/Business-Title8503 Apr 11 '25
I’ll also mention that you can record whatever you want. But a customer service agent verbally telling you something doesn’t override the contract. So you can have it on 15 recordings that a customer service agent told you XYZ over the phone so you demand to fix it and the insurance is going to say and I quote “I’m so sorry you were provided misinformation. We will work diligently to ensure all information that is provided to our customer service agents are updated and accurate. The agents who provided the misinformation will be provided direct coaching with their supervisors for the missed opportunity”. And then they will provide the written insurance contract answer. And all 15 of your recordings proving the customer service agent told me this will be for absolutely nothing.
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u/CoffeeCorpse777 Apr 11 '25
Do you have any advice for this? I can't find a recording program that works in the US, not even screen recording or Samsung voice notes
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u/Smurfiette Apr 11 '25
I use 2 phones.
One for the call and it’s on speakerphone. Second is to record the phone call.
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u/AnonymousGirl911 Apr 11 '25
I have an app called "call recorder- cube acr" and it works great for me.
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u/NoKale528 Apr 11 '25
I know it’s just dental, but we can literally get a pre-authorization a person’s name do the treatment plan. Everything’s great send it in and they deny it and there’s nothing you can do about it.
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u/Videoroadie Apr 11 '25
Maybe there’s a contract that keeps the facility or something else in network that otherwise wouldn’t be.
My orthopedic doctor has an office in a hospital but no x-ray on site. They have a contract with the hospital to allow their patients to use the imaging facilities as in network to their office. My Dr., in network. Hospital, out of network. If I went right to the ER to get an x-ray, it would be out of network, but because my Dr. is in network, it’s all good. Make sense? Anyway, knowing all this, I got a form from the imaging lab that displays my responsibilities and states the procedure is in network. Luckily I did. I fought for the next year because they wanted to charge me over $1k for three out of network x-rays after, when I my responsibility was only around $100. BCBS kept losing the fax I had provided them. The one I got from the hospital saying it was in network. Persistence prevailed though. About a year later, the exact same thing happened to my wife when she went to an outpatient facility for revision surgery post breast cancer. Her Dr had worked at multiple facilities and part of his deal was that any in network procedures he did there were to be considered in network, despite the facility’s network status with the patient. This one got resolved faster because we literally had a pre-authorization form stating in network.
Keep at it.
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u/New_Olive1203 Apr 11 '25
Do you have all the EOBs (Explanation of Benefits) AND a corresponding bill from the hospital and/or providers? Jumping from $3,500 to $96,000 after an appeal indicates the need for pause and double checking the timeline.
I know you received verbal confirmation from the Fertility Clinic about your anticipated $400 fee. Did you ever contact your insurance company to review your Fertility Coverage Benefits? Was the clinic confirmed to be In-Network?
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Apr 11 '25
Always get the pre authorization in writing directly from the insurance company! Even if the office said you’re good to go. I ALWAYS call my insurance company directly for expensive procedures or tests.
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u/sarahjustme Apr 11 '25
Dr's offices send out auto generated bills, it doesn't mean that's what you actually owe. The 96k may be what they charged the insurance company, and their computer is just spitting out statements while they wait on payment.
You need to find out what the drs office actually has, in writing, from the insurance company, in your case.
You need to confirm with the insurance company, that all claims related to this surgery, have been finalized.
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u/Entire_Dog_5874 Apr 11 '25
You need documentation of the denial in writing; you should’ve received a letter in the mail. If not request one, then file an appeal.
Every insurance company plays these games, using AI to deny everything assuming people won’t bother with an appeal. Appeals are often successful so it’s worth the time. Good luck.
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u/Lonely-World-981 Apr 11 '25
IMHO, most insurers only have an appeals process due to legal requirements, and their lawyers just look for technical reasons to refuse everything. Once you exhaust the legally required amount of appeals, they look to permanently close your claim. I would consider speaking to a lawyer who specializes in health insurance appeals.
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u/Powerful_Dingo258 Apr 11 '25
The BCBS company I work for only covers trying to find the cause for the infertility. We do not cover anything to do with actually improving conception. Call your insurance. They should be able to go over the claims and appeal results. If they can, ask them to also 3 way in the provider.
Covered is loose term by these providers. It’s on you to ask questions you didn’t even know to ask and call your insurance multiple times. It’s unfortunate but when it comes to specified procedures, it’s best to make sure of everything prior to receiving the services.
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Apr 11 '25 edited Apr 12 '25
[deleted]
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u/Intelligent-Owl-5236 Apr 12 '25
Was the additional surgeon a urologist? GYN surgeries have a pretty high rate of urology complications, so some like to have urology there just in case they think they nicked the bladder or a ureter.
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u/Tech_Rhetoric_X Apr 11 '25
First, make sure the surgeon and facility are in network.
Then, get the doctor's office & billing to do a pre-authorization and good faith estimate complete with codes. Ask for your costs.
Finally, contact the insurance company with the codes for the estimate and ask them how much you will be responsible for.
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u/ohhitsami Apr 12 '25
This is just a side note, I also went through IVF and received two hysterscopies.. they were technically preventative care and not under fertility care.
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u/nunyabizz62 Apr 12 '25
Its 96k because we live in Merika where we're stupid enough to allow such nonsense. No other place on Earth would cost that much, most would be free.
Its getting to the point to where we the customer/victim are going to have to start drawing up our own contracts and forcing all involved to sign the agreed upon fee. Something has to be done
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u/KTV2386 Apr 13 '25
Just wanted to mention, if they told you over the phone it was covered and you get to the point it needs to be appealed, the call should have been recorded and that will help you in your appeal.
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u/bmmk5390 Apr 13 '25
Always ask the insurance the billing codes for the procedures and share those with the provider so they use the right ones.
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u/Sea_Egg1137 Apr 13 '25
Did you obtain a pre-authorization from your insurance company in writing before the procedure?
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u/sunshine_tequila Apr 15 '25
Usually surgeons would submit a prior authorization for something like this. Did they do that? Usually you would get an explanation of benefits from your insurance company.
That said my ex and I had to salpingectomy and IVF and very little was covered (only meds, and ultrasounds).
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Apr 15 '25
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u/Treyvoni Apr 15 '25
Make sure it's the correct billing. I had an IUD placed (100% covered - confirmed with doc office and calling insurance ahead of time) and then got slammed with a $5k bill. Called and eventually figured it out, the doctors office had coded it under a 'injectable' BC (although correctly named the IUD brand) and injections weren't covered. In a very very broad sense, an IUD is an injectable...it's injected directly into the uterus through the cervix...
Anyway, I got that fixed with several phone calls and paid nothing.
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u/Automatic-Builder353 Apr 15 '25
I was denied a procedure by BC/BS because they said the Dr. was out of Network. He was listed on their site of Dr's in Network. They fixed the error and covered the procedure. Mistakes can happen. Good luck!
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u/Status_Fact_5459 Apr 15 '25
It’s really sad that Americans still have to go through this shit. Our medical field is third world status and people refuse to accept that. Can we please join the rest of the world in giving our citizens full health care?
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u/Hungry-Chicken-8498 Apr 16 '25
If you have a recording of your conversation with clinic that assured you that it’s covered then it’s admissible in court. Moreover, you want to call (& record) your insurance to understand why it was denied and what can you do to have it accepted. Reach out to speak with the same person you spoke with at the clinic and ask to either waive it or resubmit with correct procedure code. Also try to review all the papers you have signed to understand what were they doing to her? If you do not have copies of these documents then under HIPAA and ftc regulations you have the right to have every document you signed. Insurances are picky on procedures code and if this was an experimental procedure that means it has no procedure code of its own then insurance may decline it. If that is the case then your only rescue would be the conversation you have with clinic staff who said only $500.
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u/No-Locksmith7318 Apr 18 '25
Depending on your health plan, you need to see what they cover for infertility and infertility related services. I work in insurance and that can be a grey area based on how the providers words the need for care as well as how it’s billed vs what the plan covers.
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u/Love_FurBabies Apr 11 '25
Even though they verify benefits and state that it's covered, they do give a disclaimer that explains that the service must be medically necessary, and benefits are given based on the information you're providing. If you're Clinic is billing with a different diagnosis and different procedures, they may deem is not medically necessary. Reach out to your clinic and ask them to send all medical documentation so that they can support that it is medically necessary. They should be fighting this for you. If it's still denied, reach out to your State Insurance Commissioner and file a grievance.
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u/Tough_Cauliflower767 Apr 11 '25
Thank you. I believe they coded it as medically necessary to remove the polyps. The provider could not figure out why I was billed $3500 as they mentioned i should be $0 out of pocket minus the anesthesia fee
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