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

187 Upvotes

90% Upvoted

79 comments sorted by

View all comments

Show parent comments

45

u/AlDef Apr 11 '25

The provider doesn’t know what your insurance does and does not cover.

-16

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?

18

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).

-2

u/Tough_Cauliflower767 Apr 11 '25

That's misleading. Especially when they say all I will be responsible for is the $400 anesthesia fee

12

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.

10

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. 🙄

3

u/GroinFlutter Apr 11 '25

Ain’t that the truth lmao

4

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.