This update has been long overdue, but the past few months have been busy.
Over the summer, I shared that I received a bill from my doctor’s office with the remaining balance that my insurance didn’t cover from my bilateral salpingectomy. This didn’t look accurate to me. Under the Affordable Care Act (ACA), as long as I used in-network providers for my procedure and followed my plans protocol (pre-authorization), this surgery was covered at no charge to me because sterilization is birth control.
I used an underwriter when I looked for insurance, so I contacted her first.
She was surprised to learn that the surgery would be covered at no cost to me, which is different than being covered by insurance. At no cost to me meaning I don’t have any bills, covered by insurance could still result in a bill to me, but would be negotiated down.I pointed out ACA and sent her what I found.
We called my insurance member line together and asked a few questions. This is something you can do this on your own, and I have, but it was really helpful for me to have her assistance. In a previous post, I mentioned that I called and verified that it would be at no cost to me, and they said yes.
We asked about the procedure to file the denial claim and asked for details of the recording from when I called in March because they would’ve had a record and notes.
When I wrote my letter I cited ACA verbatim, my policy details, the call, the pre-authorization letter that deemed this procedure medically necessary and provider number to prove they were in-network.
In September I received an updated EOB (explanation of benefits) from my insurance saying that I didn’t owe anything for the surgery itself, which was exciting. However, I had facility fees, which was what the balance from my doctor’s office was reflecting.
This was frustrating to see because you can’t have surgery without having a facility to have surgery. This is where the language matters, how information is explained also matters.
Like other hospitals, I spoke with the finance office and set up an interest free payment schedule. She told me I could pay as little as $50 a month. Luckily, I was able to pay more than this and I will have my surgery paid off by early next year, but I know for others this would be a huge hit to how they budget and plan.
I’m happy that I had surgery. I would do it again, even if it did cost me more. I’m also pissed that there’s a language loophole and that’s how hospitals and insurance companies get around covering these fees.