r/HealthInsurance • u/ukchic1 • 1d ago
Plan Benefits I had preauthorization and now I owe $27,000 because Oxford won’t cover it
I’m honestly besides myself and I don’t know what to do. I had Preauthorization from my insurance covering egg freezing and now Oxford is saying that Cornell are billing the wrong code and that they won’t cover it.
Oxford is saying “its denied due to the provider billing a procedure code that was not approved by the prior authorization s4021”
Cornell is saying “that the codes S4020 and S4021 are not reviewed by the insurance. The billing code used S4021 is correct with our contract with the plan in treatment cycle”
I’m absolutely beside myself. I don’t have this kind of money at all and as a single mom of 1 going through cancer treatment this will bankrupt me. I can’t wrap my head around how this happens when I have preauthorization of coverage.
Has anyone else had this happen? I am beside myself.
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u/tacosandspark 1d ago
So Cornell got auth for a full cycle code and not the freeze all ( which a assumed that was what you were doing with going through cancer treatment) the S4021 is the correct code for a freeze all but they didn’t get it authorized. That is an error on their end.
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u/ukchic1 1d ago
But now somehow I am responsible for payment and they are refusing to bill code s4021
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u/Old_Draft_5288 1d ago
You’re not. They fucked up. Be clear and tell them you’re seeking legal representation to deal with their error.
If they told you the whole set of procedures was pre-authorized by insurance, and they put the wrong codes in, it’s their liability.
But if there were services not in the pre auth, then they also failed to communicate with you.
Before undergoing a procedure this pricey, they should have given you an estimate of costs. Did they do this?
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u/future_seahorse 1d ago
Along these lines, given that you’re doing this prior to cancer treatment, there’s no way they can try to say they didn’t know that this would be a freeze all cycle. So, it’s not like they can try to say you miscommunicated with them. There’s no reason for them to have gotten the full cycle vs freeze all code wrong, except them messing up, which they clearly did.
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u/finchlings 1d ago
Can you or your provider request a post-service review to have the additional codes added to your PA? Or are the codes just not covered at all under your policy?
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u/EffectiveEgg5712 Carrier Rep 1d ago
So what codes were approved on the prior auth letter?
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u/ukchic1 1d ago
Codes S4015 58970 89337 89346 S0128 S0122
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u/EffectiveEgg5712 Carrier Rep 1d ago
Welp that is the issue. They are indeed billing codes that are not in the pa. I would verify with insurance if the codes they are billing require a pa or not. If they don’t, ask if they are subjected to medical review.
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u/ukchic1 1d ago
Thank you
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u/EffectiveEgg5712 Carrier Rep 1d ago
I saw an updated comment that the cryo was denied because it was non covered sooo that may be an issue. On all of our plans, cryopreservation is an exclusion. If that is the case, those usually deny member responsibility. That would be another thing to verify when you call them. Ask if you have the benefits or is it an exclusion.
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u/positivelycat 1d ago
Is the provider in network and does your EOB say you owe 27k or zero?
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u/ukchic1 1d ago
Yes in network and it’s Oxford saying they covered $0 and that I “may owe” three seperate charges of $1250, $11,000 and $15,376 saying Oxford is paying 0$ on each one
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u/positivelycat 1d ago
What's thr denial reason. Not all services require prior auth especially if they are just non covered under the plan.
No prior auth if required by the plan is the provider responsible anything else likely less so
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u/ukchic1 1d ago
It says the denial reason is not a covered benefit CES005
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u/positivelycat 1d ago
Ok so your insurance is saying basically this is not covered under you plan. Could be that they never cover it could be they only cover if xyz is meet. Either way no prior auth is needed which likley means even if the provider tried prior auth insurance would just say non is needed.
. Call billing asking for the cpt and dx code to review maybe something is billed wrong. Also call your insurance to confirm if this is ever a covered service and if you can appeal.
If that does not work ask for a self pay rate to see if the provider can reduce the fees
I
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u/zeph816 15h ago
This is the correct answer if the denial was non covered service.
If they issued a PA for a non covered service and then denied it, that would unfortunately be correct.
Insurers will authorize non covered services sometimes. I know that doesn’t make sense and that you would think that they cannot deny if you have a PA, but that isn’t how it works.
I was trying to reply to the comment from positivelycat
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u/brandyfolksly_52 1d ago
Ask the provider's billing office if the codes billed are crosswalked with approved codes on the prior authorization (for example, if code "A" is approved on the authorization, but your provider billed code "B," which is not approved on the authorization; but, "B" is on the insurer's prior authorization crosswalk table, as crosswalked with "A," then they should accept "B" in place of "A".). If the billed codes are crosswalked with approved codes, then the insurance needs to reprocess the claim.
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u/Old_Draft_5288 1d ago
That’s your providers problem, not yours. They messed up the pre auth. You don’t owe this. If they are in network, they are fully responsible for accurate pre auth and billing codes. If they sucked up, it’s on them.
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u/livingunderarock720 1d ago
Livestrong also has a grant. I would look into this just in case. https://livestrong.org/how-we-help/livestrong-fertility/ Back when I applied I remember them (their representatives) being very helpful and answering all my questions even though I didn’t end up using their grant.
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u/ajk_1987 3h ago
Rev cycle person here who oversees billing and auth- a lot of codes do NOT require an auth and insurance will not review them, hospitals only auth for what insurance says needs to be reviewed.. if your insurance says this is a non covered benefit - that means it’s an exclusion on your plan. I suggest asking a hospital financial rep to do a 3 way call with your insurance and determine if there’s anything that can be appealed
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u/PharaohOfParrots 1d ago
Walgreens has a grant, but I don’t know if it’ll help. https://www.walgreens.com/topic/pharmacy/specialty-pharmacy/fertility-preservation.jsp
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u/Decent-Loquat1899 22h ago
Contact your state department of insurance and ask whether your state allows your insurance company to revoke authorization. Get the statute code if they’re not allowed to. Send a detailed letter to your insurance company and file a complaint with your department of insurance. Now for the really bad news. Thanks to President Regan, health insurance companies are immune to state civil suit UNLESS filed in Federal court. If you seek an attorney, you need to find a ERISA attorney.
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