r/HealthInsurance 29d ago

Claims/Providers Their website says they are an urgent care, the sign on their building said Urgent Care, the sign over the counter said Urgent Care, now they are billing as a doctor's visit and my health insurance won't cover it.

130 Upvotes

Earlier this year I dislocated my knee. Despite not being able to even stand up and having to be carried into a car, I did the right thing and I looked up my health insurance and they cover urgent care at 100%. I looked up physical therapists on my health insurance website and there was an Orthopedic Urgent Care in my city and in network! I went there, the building said urgent care on the side, it was a Sunday and the ONLY thing they offer on Sundays is urgent care per their website. They X ray me, confirm no tendons were torn, and send me home telling me to ice it and rest. A month later I receive a bill for well over $500. I look, my insurance paid out $12 and I was on the hook for the rest.

I called my insurance and they said it was because the PA I went to billed it as a doctors visit. I called the urgent care and they informed it its because according to the woman I spoke to, they are NOT an urgent care and do not bill as one. When I asked her how they could have "Urgent Care" on the side of their building, on their website, and on my health insurance's website she stopped talking and said I had to speak to a manager, then put me through to a voicemail, where the manager will not call back. I've tried several times and the same routine. The person on the voicemail who is only identified as "Bob" will not call back and does not have a phone number.

It's been several months of this. My company pays for a health advocate so I used them and they opened the case, told me it was billed correctly, no explanation, and closed the case. I called them and they said they called and were told that it is not an urgent care and that was that.

This is a major hospital in my city, its name is on the side of an NFL practice facility, they have like 20 locations. They have ads on the radio as an urgent care. Why will they not bill as an urgent care. My own insurance has said they'll pay if they change their billing but they will not. I've told them I wont' pay until they do and they said they'd put it to collections. Why would they refuse to bill for the service they provided and go through all this work?

In my state (MN) the attorney general's office will investigate claims on your behalf and I'm debating going down that route, but before I go through this step, can anyone explain to me why they can advertise as one thing but bill as another? Is there something obvious I'm missing?

Edit: To clear up a comment below, it was an Orthopedic urgent care, not a PT. The organization does both orthopedic urgent care and PT but who I saw was on the orthopedic side. I used the wrong term.

Also, as I read the bill closer, my insurance paid out $0, but the urgent care being in-network they did a $12 adjustment (instead of the 100% as it says on the back of my insurance card).

r/HealthInsurance Jul 30 '25

Claims/Providers Referred to ER from Urgent Care, surprise bill.

84 Upvotes

My 7 year old son was hit with a rock in his temple at a local playground. There was lots of blood, but overall a pretty minor injury. We went to urgent care to have it checked out, get stitches if necessary, and have professional give us an all-clear on a possible concussion. (I had just taken the CDC course a few weeks prior, no visible signs of one)

Urgent Care saw us pretty quickly and was able to clean my son up. At this point he was no longer bleeding, and the gash was pretty small considering the large amount of blood. The nurse on duty told us we should take an X-Ray, not really sure why. After this recommendation, they refused to do any further work on him or give him a stitch. There was no doctor on duty at the moment, not sure if that has anything to do with this. They call a local ER company and away we go, now wondering if it's necessary to even show up.

At the ER, we are told about incompetence of Urgent Care workers and "We would never XRay for this type of injury, but we could do a CT scan. Although we don't recommend it for a child!" All in all, a very weird interaction with the doctor but that's fine. We attempted to ask about billing, only to be told they will bill our insurance and get a bill later for the balance. The doctor at this point decided to numb the cut, wait 45 minutes, then apply a single stitch. This could have been a band-aid at this point. It really no longer felt necessary.

Three months later, bills have finally come in. My insurance provider is UHC, which I get through my company. I pay for the highest-tier plan just to avoid surprise bills.

Urgent Care, $75
ER Doctor, $1,141. Insurance plan discount $859, I owe $282.
ER Facility, $7,072. Insurance plan discount $5,432, I owe $1,600

Feeling a bit overwhelmed as I attempted to go about this in the correct way. My impression was that I go to an ER, pay $250, and I'm done. But now I see I owe the first $3,000 annually. Is there not a way to get insurance to pay this out since I went to Urgent Care first and got a referral? Are there any ways to reduce this bill? Really appreciate the feedback!

EDIT: I appreciate everyone's feedback. I've gone through it and it feels like I'm just going to have to absorb the cost. I'm 40 with three kids, this is the first time I've ever had to go through emergency care with anyone. Lessons learned. Thanks for the education, once again it's appreciated.

r/HealthInsurance May 20 '25

Claims/Providers UnitedHealthCare does not cover my colonoscopy

115 Upvotes

I passed 45 years old, and just had my very first screening colonoscopy according to Dr.'s suggestion, and received 4 bills from the provider, totaling more than 3 thousand dollars. I thought screening colonoscopy is supposed to be fully covered by the insurance, right? UHC's reason is that there were polyps found during the procedure, thus it is no longer screening. I heard UHC is famous at denials, but is this a valid reason to not pay for it? What options do I have to appeal?

Thanks.

r/HealthInsurance 29d ago

Claims/Providers Dropped by a provider because BCBS won’t fully pay out claims

112 Upvotes

For context, I have Crohn’s Disease and have been getting my medication via a blood infusion every 6 weeks for the past 7 years.

I received a call from my infusion center yesterday and they said they have to discharge me (and everyone else who has BCBS) because even though these treatments are covered by insurance, the provider is having trouble fully recovering the costs from BCBS. They said that each time they submit the claim to BCBS, they’re not being paid back for the full amount and so it’s not financially profitable for them to have BCBS patients anymore…

I don’t understand how it’s legal for BCBS to not fully pay back the claims if they’ve already agreed that these procedures should be covered by insurance. This is the first time I’ve dealt with this issue in the 7 years I’ve had these treatments, and I’m not sure what to do next or who can advocate for me.

r/HealthInsurance 4d ago

Claims/Providers Therapist misled me about in-network status - now stuck with bills

26 Upvotes

I found a therapist through my insurance website and started seeing them.

For about 6 months, my therapist didn’t submit anything to insurance and only charged me my in network co pay.

They just started submitting claims to insurance and it turns out that my therapists contract with my insurance company ended shortly after our first session and was not renewed for 6 months. My insurance is showing claims for ~$200 per session as if I were out-of-network for those 6 months.

My current plan is:

1.  Talk to my therapist to see what they think the best path forward is.

2.  Appeal with my insurance.

3.  If needed, file a complaint with the NY Department of Financial Services for a surprise medical bill.

I’m in New York. Has anyone gone through something similar? Any advice on how to handle this would be really appreciated. Thanks in advance!

Edited post for clarity.

r/HealthInsurance 5d ago

Claims/Providers Insurance denied claim saying it's cosmetic

70 Upvotes

I have Anthem Blue Cross and Blue Shield and am in Indiana

I needed to see a dermatologist due to some concerning spots. I asked my insurance who was in network and they gave me a specific doctor's name to go to and said I don't need a referral, and that I'd just have to pay my copay of $25.

So I went to her. While there, she diagnosed the spots and said one was precancerous and removed it with liquid nitrogen, to prevent it from turning into cancer.

I get a letter from the insurance denying coverage for everything and saying they need more information, but showed the whole total as like $198. I tell the derm office. I get another letter from the insurance saying they'll pay for part of the visit, but nothing for the removal because it's cosmetic, with the same cost listed and a certain portion I need to pay. I ask the derm to send them my charts or something showing that it was removed so it doesnt turn into cancer, and that it wasn't cosmetic. I then get another letter from insurance saying the same thing and the total for everything is now almost $1400, and a bill from the dermatologist.

So, is getting a precancerous lesion removed considered cosmetic and not medically necessary? My insurance company is usually pretty big on preventive measures, but seems not this time.

I guess I have to edit to add- I'm 36, pretax income is about $110k.

r/HealthInsurance Dec 06 '24

Claims/Providers United Healthcare denial of claim for inpatient services

371 Upvotes

My wife passed out and split her head open on the floor so I took her to ER. She passed out due to loss of blood and high white blood cell count. She was aware of these issues and was supposed to see the gyno the same day. The ER gave her 11 stiches and performed diagnostics to determine the case. They said she had an "acute UTI" and gave her antibiotics among other medicines. The ER doctor said her blood count was low, white cells were high and had an elevated heart rate. He determined she needed to be checked in as a inpatient for a day or so until she stabilizes.

They wheeled her in a chair and checked her in for a few hours and decided to let her check out so we could see the gyno as planned. The gyno recommended removal of our uterus lining and all is good now.

Later, we received a notice from UHC that her claim had been denied. Here is how it reads:

You were admitted to the hospital on _____. the reason is Kidney infection. We read the medical records given to us. We read the guidelines for a hospital stay. This stay does not meet the guidelines. You did not have to be admitted as an inpatient in teh hospital for this care. The reason is you were watched closely in the hospital. You were stable. You had tests that did not show any problems that needed inpatient only treatment. The records showed you did not have fevers. You could have gotten the care you needed without being admitted inpatient at the hospital. The hospital inpatient admission is not covered. We let the hospital know that is is not covered.

The letter goes on to imply that we are on the hook for the stay but at no point were we given any options to seek treatment elsewhere. We just did what the ER Doctor said. The hospital did not tell us we would not be covered. My wife was absolutely not stable for the reasons mentioned earlier.

We tried to appeal but it got denied and on that letter they mentioned the claim was $16000! We were only there for like 3 hours.

Is the hospital on the hook for this? I read they have to tell us if something is not covered or out of network but I read other shady things that UHC is doing so I'm very concerned. There is no way we're paying this by the way.

r/HealthInsurance Jul 09 '25

Claims/Providers In my experience, "paying cash is cheaper than paying with insurance" is a myth

50 Upvotes

In the United States, I'm sure some of us have been told at least once that we can pay cash at doctor's offices to get some sort of magical discount.

I've had both high deductible United and Blue Cross Blue Shield over the past few years. Every time I've needed care, I've checked the negotiated rate vs. the doctor's cash pay rate. I live in New York City.

Every single time, the negotiated rate has been lower than the cash pay rate. Sample size of over 100.

As a patient, I'm financially incentivized to create more work for the practice with the additional billing paperwork and more work for me dealing with my insurance. What a nonsensical system!

I've even tried explaining this to practices and asking them to cash match my negotiated rate or give me a discount for saving them the time with billing. They won't.

r/HealthInsurance Jun 06 '25

Claims/Providers OBGYN sent bloodwork to out-of-network lab without consent

94 Upvotes

I had bloodwork done back in March at my in-network OBGYN. They did the testing through Natera, which is out-of-network, and I just received a bill for over $500 for a single test. Now, from what I've gathered, this is usually a too-bad-so-sad situation, BUT I have a copy of the consent form I signed at the time of blood draw and it specifies "I understand that my testing will be sent to an IN-NETWORK lab".

How do I make this go away? Can I just... not pay it? I'm already paying over $6k out-of-pocket to my OB in delivery fees. Any help is greatly appreciated.

EDIT: Thank you to everyone who gave actual advice and insight. I am going to be a first-time mom and this is all a learning process for me, so patience and kindness is appreciated. I assumed that the consent form I signed was for all of the bloodwork I had done on that day, when it most likely did not include the optional NIPT test. I'll definitely be in contact with Natera about self-pay.

I think it's important to remember when responding to posts in this subreddit that the majority of people asking for advice here are feeling cheated, manipulated, and financially unstable due to the horrible state of American health insurance ❤️

r/HealthInsurance Apr 13 '25

Claims/Providers Lab work denied "Not Medically Necessary" now have $3000+ bill

105 Upvotes

I am currently dealing with a situation where my hematologist ordered some blood work that unknown to me at the time that they took the sample, one of the tests was not covered.  Fast forward 4 months after that appointment, my insurance company, Anthem Blue Cross of CA, denied the test which turned out to be genetic testing to see if I had a rare blood mutation that had a very minor impact on my health if any.  At my next visit with the hematologist I asked about it getting denied and he got very defensive saying that it was medically necessary. His office appealed the decision on my behalf. 

I just found out that the insurance company had denied the claim again saying that it was not medically necessary again.  I am at a loss as this one test is being billed at over 3000 dollars which had I been told this would be the cost, I would have never had said to test for it.  I called the insurance company and the only appeal I have right now is a level 2 appeal which seems like a long shot at best.  Due to the length of time this has been appeals, it has been sent to an internal collections.  They know it is in appeals but I need to figure out how to get this resolved without me paying the bill that, in my opinion, the hematologist’s office should be on the hook for the cost of the test as they neglected to check if the test was covered and just sent it out.

Do you have any advise for me for next steps? Thanks in advance

r/HealthInsurance 20d ago

Claims/Providers UHC denying medically necessary cancer genetics testing, which was the second option since they wouldn’t approve a mammogram.

57 Upvotes

Hello,

My mom had breast cancer at 32.

My father had skin cancer at 48.

My grandmother had ovarian and thyroid cancer before the age of 30.

I have already been Dx’d with moderate atypia of the skin which has required two MOHS surgeries

I have already been Dx’d with a BIRADS-3 breast mass and a TIRADS-4 thyroid nodule. I have also had precancer of the cervix, which required surgery. It progressed from CIN 1 to CIN 3 in a matter of three months, which is almost unheard of.

This all led my OBGYN to order a mammogram for me. This was denied.

She finally said fuck it, we will send you to a geneticist - if you test positive for BRCA or other relevant cancer genes, your insurance has to approve other testing and procedures for you.

But United just denied the testing ordered by the board certified geneticist because it wasn’t medically necessary.

So what now? I waited 7 months to see the geneticist and another month for the test to get denied. I’m frustrated. I know my geneticist will probably go to bat for me, but I know of the United horror stories.

Is there any chance I wind up having to pay thousands of dollars for this? Should I wait it out? Do I have other options?

Edit:

Everyone in the comments has been so wonderful and helpful and I am extremely grateful for all of you. When I posted this, I had just woken up to the news of the insurance denial and I posted this in an emotional heat of the moment frustration. My therapist had me stop googling stuff related to my health earlier this year, which I had become good at, but after reading all of these comments I realized that there are things I do need to be knowledgeable about in regards to this process, and that I definitely need to kick myself into gear for the time being.

I have already alerted the geneticist of the insurance issue, and they told me to message them in the portal as well. A commenter posted this link:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/whole-exome-and-whole-genome-sequencing.pdf

Which made me realize that there are other relevant things that I wasn’t aware were relevant, and hadn’t mentioned to the geneticist during our consultation.

I am about to spend the rest of my evening pulling all of the relevant medical records and information and compiling it into an e-mail for the geneticist so that they are aware. I also contacted the genetics lab requesting information on their patient financial assistance program, and I plan on paying out of pocket for a mammogram later this month or early next month, and I also have a follow-up ultrasound this month as well.

Hopefully with the new info, the geneticist can either get my insurance company on-board, or send the order to a lab that offers a cheap self-pay option if Variantyx cannot assist. The package already arrived, but I haven’t opened it and don’t plan to unless everything is sorted out.

Thank you all again for the encouragement as well as helpful links and information. It means the world to me! I have felt like a looney toon for the past few weeks being only 26 y/o and even looking into this type of testing, almost gaslighting myself into thinking it was overkill, so I really appreciate all of the support.

r/HealthInsurance Dec 12 '24

Claims/Providers UHC DENIAL

317 Upvotes

There needs to be a UHC denial subreddit just to post this ridiculousness. UHC denied my MRI (had back surgery 2.5 years ago and still having issues). They said I need to do an x-ray first (as they do), but also denied it because I didn’t do PT for 6 weeks. Ya’ll, I’ve been doing PT for 6 months, but have been paying out of pocket since they denied it when I started 6 months ago! I keep submitting my bills and they keep denying it! It’s just insanity

I should add that I just paid for the MRI out of pocket bc l’ve been asking doctors for an MRI since my surgery and this was the first doctor willing to write the script.

r/HealthInsurance Apr 11 '25

Claims/Providers 96k bill not covered

188 Upvotes

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

r/HealthInsurance Feb 27 '25

Claims/Providers Had an emergency hip replacement. Hospital put me in a private room and insurance will not cover it. It's over 10k and I never requested it.

264 Upvotes

As the title says. I woke up from surgery and wheeled into a room without even knowing what was going on. I had emergency surgery to replace my hip from an accident. Insurance now says I owe over 10k becuase a private room was not necessary and they only cover semi private rooms.

What can I do here? I was expecting to only have to pay my max out of pocket rate. And now this is a huge upset.

Thanks in advance for any insight.

EDIT: I appreciate everyone's comments. I am going to call Hospital Billing to see what they can do. I will update when I find out the results.

For anyone looking at this in the future. I am in Texas. These are the codes that insurance used to deny the private room rate.

1 According to our guidelines, a private room was not medically necessary. Therefore, the payment is being made at the semi-private room allowance. J8530

2 The difference between the private and semi-private room charge is your responsibility. Private room is not a covered benefit for the reported diagnosis. Y5519

r/HealthInsurance Apr 02 '25

Claims/Providers I’ve never hit my deductible before - what do I do now?

164 Upvotes

I had a baby back in January and received a hospital bill for a little over $7000. I paid the full deductible and maximum out of pocket costs a few weeks ago. I don’t understand how health insurance works at all so I’m not sure what to do with the remaining balance. Do I pay this or does this get resubmitted to my insurance now that I’ve met my deductible?

I called the hospital and they said to call my insurance company. I called my insurance company and they said to call the hospital. My insurance is through United healthcare. Anyone know what I do next?

Thank you!

r/HealthInsurance May 15 '25

Claims/Providers Dr refuses to sign form to collect disability

61 Upvotes

My husband had a heart attack and was taken to a Stent Lab in another state. We have an Aflac policy for short-term disability we’re trying to collect on. There are 2 forms- one for the employer which we have, the other for a physician. The treating cardiologist is refusing to fill out the form. His part is only 1/2 page. We have asked his primary doctor to do it and waiting for a response. It’s unreasonable for the cardiologist to not cooperate. What can we do. Can’t collect on disability without it. He can’t work for two months and medical bills are mounting.

We are clear on what to do. Thanks go all who responded.

Edit: Just got a call from PCP and she is also refusing to sign it. He has another appointment with a cardiologist here in TN on Tuesday. Hopefully he’ll do it. Sigh…

2nd edit. Cardiology specialist finally signed it. 4th physician asked is a charm. This shouldn’t be so hard.

r/HealthInsurance Feb 24 '25

Claims/Providers Urgent care sent us a bill for $400 for a flu test, then told us it was an accident when we called?

176 Upvotes

Edit: the amount of people defending a $900 mistake is a little dystopian to me lol. The idea of going to a doctor and not being able to trust that I’m paying the right amount is crazy. I understand everyone is human, but that mistake can literally make or break someone who just assumed it was correct. People do make mistakes but they also need to be held accountable when they’re sending out letters asking people to just “pay up” for a large amount like that. These are people’s lives, finances, and their health. To be so nonchalant about a mistake like that is unnerving. For any billers/coders that I offended - apologies!

My husband went and got a flu test and he received an over $400 bill.

It was originally over $1k, insurance covering $650.

The two things on there were for a flu test, and for a “visit with someone of moderate decision making”.

When we got the $400 bill my husband called and asked why he’s being charged $400 for a flu test. They looked into it and said that they accidentally miscoded it as a “full respiratory exam”? And that they were going to re-review it.

This doesn’t sit right with me that they can just “accidentally” code it as the wrong thing. Does this happen often? Should we be reporting them?

r/HealthInsurance Dec 19 '24

Claims/Providers Hospital violating No Surprises Act

423 Upvotes

I was in a car accident and taken to a hospital from the scene, I received many bills and paid them as they matched my insurance EOB. Then I received a bill for $18,500 however the EOB matching that bill states patient owes $1,222. I spoke with the hospital billing and they said it’s because insurance denied the claim. Then I spoke with insurance and they confirmed the claim was processed and this claim is No Surprises Act qualified, so I owe what the EOB states.

I call the hospital again and advise them insurance told me to either contact the provider or file a complaint. The hospital keeps saying they’re pushing the bill back but I keep getting calls about the $18k they claim I owe. Do I proceed with filing a complaint against the provider? Since my insurance told me that it is qualified for protection under the No Surprises Act

r/HealthInsurance Mar 14 '25

Claims/Providers Being charged $50 for prior authorization?

10 Upvotes

To start: I live in Texas, have Blue Cross Blue Shield HMO, and the relevant provider is in-network and my referral was already approved.

I have narcolepsy, and am about to start a specialty drug called Xywav for my treatment. It needs a prior authorization before I can start it, but the sleep neurology practice is charging me $50 to submit the prior auth. That seems insane to me, but I also really need the medication and don't know who I would speak to about this. I already called my insurance and they couldn't give me a solid answer, just that they had never heard of a prior authorization charge for someone in-network. This provider has been a shit show in general, but sadly there isn't an abundance of sleep neurologists.

Any suggestions for my next steps? Thank you.

r/HealthInsurance Dec 26 '24

Claims/Providers Bill was 7x the Good Faith Estimate

212 Upvotes

Hello. Before a procedure, I called the provider for a Good Faith Estimate. They have my insurance on file and ran it through the insurance. I got an estimate for the procedure, along with the CPT codes. I followed up by calling both my provider and health insurance company to ensure this estimate seemed accurate. I do the procedure. Weeks later, I get the bill which is seven times higher than the estimate. I was told by both over the phone that it was indeed accurate. I understand an estimate is just that, an estimate. But 7x higher seems like a misleading estimate. I called the provider to ask why there is a discrepancy. While the billing head told me the Good Faith Estimate was inaccurate and did not pull the benefits correctly, there was nothing she could do. Essentially, “We gave you a bad estimate. We acknowledge that. Oh well, give us the money.”

What’s the point of a Good Faith Estimate if it’s not going to be in the ballpark? Do I have any recourse or no? Would this fall under the No Surprises Act?

EDIT: Thanks everyone for taking time out of their holiday weeks to respond. TLDR: seems like there is nothing that can be done.

r/HealthInsurance 13d ago

Claims/Providers Help me understand why this would be denied

25 Upvotes

I am having surgery in October. I hit my OOP max and the surgeon and hospital are both in-network. I am however being charged a fee for a modifier that the office is saying will be denied. It’s modifier 22, where more time is needed than the typical surgery length. The surgeon estimates just under three hours for my surgery when it is normally about an hour and a half because of the level of complication he expects. They are telling me thus modifier is always denied every time it is used with his surgeries. What is confusing me is the fact that the receptionist is warning me that insurance will claim it will be covered but it is not:

“The modifier of 22 is denied for [doctor] on a continual basis. Your insurance carrier will advise you this is covered. It is not, nor would a prior authorization get this modifier covered. [doctor] is a single, provider specialist, not a GYN as most insurance companies have us coded as. We WILL submit for the modifier 22, and if they pay, issue you a refund, as applicable once the claim has been finalized and payment received in the office.”

They are charging me the fee for it overly confident insurance will deny it. I am just very confused why it would be denied and why insurance would lead me to believe it would be covered when it’s not.

r/HealthInsurance Apr 02 '25

Claims/Providers LifeX research core/Anthem PPO

13 Upvotes

An insurance agent is trying to sell me on a plan that includes joining the lifeX research corp as an employee to just fill out surveys… And the coverage for medical insurance is through anthem PPO. Coverage is around $500 a month with $1000 deductible, and it's only a $250 co-pay to give birth. It seems too good to be true… And I can't find any information online, does anyone have any experience with this company?

r/HealthInsurance Jul 22 '25

Claims/Providers Is my Doctor getting a kickback from a drug manufacturer?

31 Upvotes

A few months ago I started receiving 3x weekly allergy shots through an allergist. (Immunotherapy) I recently had a mild allergic reaction to my allergy shots, my doctor prescribed an epi-pen. The doctor's office then sent me a link to a manufacturer that said the pen wasn't covered by my insurance and I needed to pay the company $250 for the prescription

I called the nurse back and asked to send my prescription to my normal pharmacy where I paid $20 (partially covered by myinsurance) for a generic of the same

I'm wondering why my Doctor's office would send me to the website that was charging so much. I checked OpenPaymentsData and found the name of the manufacturer and my doctor, with a small payment listed.

Is there a financial relationship here? Why would my Dr's office send me to a manufacturer for a medication that's more than 10 times what I would otherwise pay?

r/HealthInsurance 5d ago

Claims/Providers Clinic did not get prior authorization for my CT scan and now I'm hit with a $2000 bill

11 Upvotes

Because my allergies have been flaring up really bad recently, my allergist referred me to an ENT to check for structural issues with the sinuses. I got a nasal endoscopy and CT scan at the ENT clinic, at the time of visit, I was only charged with my copay and deductible, however, weeks later I am hit with a nearly $2000 bill from the ENT clinic, who claims insurance didn't pay for any of it.

When I called insurance, they said that because my plan (United Healthcare Student Resources) excludes coverage for all nasal and sinus surgery, diagnostic procedures such as a ct scan also counts as "surgery" and is excluded. What a whole load of nonsense, I can't believe Insurance can get away with this.

I then called my ENT clinic, who told me they did not get prior authorization from my insurance, or even called my insurance at all. They claim that "they don't know what the doctor will perform during the visit", so they only notified insurance after the procedure has been performed. They also filed me under the diagnosis code for chronic sinusitis, which is NOT the condition I have, I have allergist rhinisitis or some sort of allergy-related sinus problems.

The ENT clinic also claims that insurance didn't pay because I haven't met my deductible, because I have student insurance, my deductible is $50. So you're telling me after being charged with a nearly $2000 bill my deductible still hasn't been met?

I am so confused, insurance says one thing and the clinic says another. They just keep spinning me in circles. How can a clinic get away with not getting prior authorization for any of their patients? The billing rep even had the audacity to say that "it's unfortunate that when we file the claim insurance denies so many of them and so many patients have to pay out of pocket." What??!

What do I even do at this point, at any other clinic I have all been informed regarding my insurance approval before getting any procedure. I guess I was careless and just assumed this very big, very reputable clinic as recommended by my allergist would do the same.

r/HealthInsurance Mar 12 '25

Claims/Providers Got billed for having an irregular period

53 Upvotes

A few months ago, I got an annual preventative exam at a new doctor. At the end of the appointment, I mentioned that I had an irregular period. All of my doctors in the past have proactively asked me about my period, and I figured I should mention it as part of my medical history. The doctor said to do routine bloodwork and no further discussion was had. This entire “discussion” took 2 minutes at most.

When I received the bill, they filed two claims: one for a preventative exam and one for a diagnostic exam for amenorrhea (irregular period). Without my knowledge, the doctor ordered a bunch of extra lab tests and an ultrasound for the irregular periods, even though I just stated this to track in my medical history. I did not do any of the lab tests or ultrasounds. Am I crazy or should I not have gotten billed for a diagnostic exam? In their words, a preventative exam includes “age and gender appropriate history, exam, counseling, education, and necessary lab work or imaging”. How does an irregular period violate the boundaries of a preventative exam? I have tried to dispute this twice, and they claimed this isn’t covered under gender-appropriate medical history. On the phone, the billing department even said that amenorrhea can be billed as either preventative or diagnostic depending on the context…seems it should be preventative to me.

If it’s helpful, the billing code is 99213, which is a 20-30 minute appointment with a patient with a stable illness/minor injury that requires a low-level of medical decision making. In my opinion, stating a fact about your medical history does not require any medical decision making, and I did not ask for any labs to be ordered. I would not consider this to be a “diagnosis”.

Also, after this happened I looked into the healthcare provider and they have been sued for systemic double billing by the DOJ…I definitely won’t be going back 🙃

Any advice is appreciated!