96k bill not covered

[u/Tough_Cauliflower767]

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

[u/AnonymousGirl911]

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.

[u/LizzieMac123 → u/AnonymousGirl911]

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.

[u/Business-Title8503 → u/LizzieMac123]

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.