Clavell's Office Fuck Up on Insurance Pre Auth, Any Ideas?

[Midwest Guy 333]

When considering this surgery, I specifically asked Maddie at Clavell's office if my insurance would cover it and if so, what my total out of pocket cost would be. She assured me it would be covered and gave me the figure I would be paying out of pocket. I absolutely never would have had the surgery if my insurance (UHC) did not cover it. Had the surgery in January.

Fast forward to March. I get a bill from the hospital. After investigating that, the insurance person at Clavell's office told me that they didn't think they needed pre auth in order for the surgery to be covered. After the surgery, UHC told them that they did and since they hadn't obtained it, insurance would not pay. WTF? She went on to say that it was their fault and their office would eat Clavell's charges. All fine and well, but what about the $366,000 ridiculous amount the hospital billed? So, Clavell's office appealed to UHC. They denied it again.

Now, I am expecting to receive an exhorbitant bill from the hospital. I called Clavell's office today and talked to a different insurance person. She said they already admitted fault and did not charge me for Clavell's fee. Great, but what about the hospital? She said they had nothing to do with that. I corrected her and said they had everything to do with it as I would never have entered the hospital doors if I had known my insurance would not cover the surgery and that I would definitely be contacting Clavell's office again if I get a bill from the hospital. She then hung up on me.

Has this happened to anyone else? Any advice? Thoughts on recourse? As far as I can see, if I get a bill from the hospital and I don't see why I wouldn't, I'm looking at engaging an attorney to sue Clavell's office.

[frank66665]

I have a hard time understanding the billing and justification of $366,000 dollars, but were you dead and they brought you back to life? but the law doesn't exist there? they should arrest them all without you needing to get a lawyer

[GJGordon]

$366.000.00..............WTF..............does he mean $36.000.00...........how much is the surgery anyways....

[Alex258]

When considering this surgery, I specifically asked Maddie at Clavell's office if my insurance would cover it and if so, what my total out of pocket cost would be. She assured me it would be covered and gave me the figure I would be paying out of pocket. I absolutely never would have had the surgery if my insurance (UHC) did not cover it. Had the surgery in January.

Fast forward to March. I get a bill from the hospital. After investigating that, the insurance person at Clavell's office told me that they didn't think they needed pre auth in order for the surgery to be covered. After the surgery, UHC told them that they did and since they hadn't obtained it, insurance would not pay. WTF? She went on to say that it was their fault and their office would eat Clavell's charges. All fine and well, but what about the $366,000 ridiculous amount the hospital billed? So, Clavell's office appealed to UHC. They denied it again.

Now, I am expecting to receive an exhorbitant bill from the hospital. I called Clavell's office today and talked to a different insurance person. She said they already admitted fault and did not charge me for Clavell's fee. Great, but what about the hospital? She said they had nothing to do with that. I corrected her and said they had everything to do with it as I would never have entered the hospital doors if I had known my insurance would not cover the surgery and that I would definitely be contacting Clavell's office again if I get a bill from the hospital. She then hung up on me.

Has this happened to anyone else? Any advice? Thoughts on recourse? As far as I can see, if I get a bill from the hospital and I don't see why I wouldn't, I'm looking at engaging an attorney to sue Clavell's office.

I had a similar issue.Had the surgery after being pre-approved back in November 2022. Appealed with my insurance company and denied 3 times, no lawyer wanted to touch this so I am on the hook for $44,000. I thought the total was for $30,000 and I did sign the paperwork after being assured all was covered. Dr's office kind enough in giving me lots of time and will begin makings small payments to the hospital first. Your bill is way out of line and if I were you I'd be suing left and right. That is so very wrong. GL to ya.

[Midwest Guy 333]

Alex258,
Who was your surgeon and what insurance do you have? I would think any attorney would jump at a chance to go after this. Why was that not your case?

[jwdetails]

Wow that is quite the bill. I know when they bill insurance especially when its completed in the hospital the try to fluff up the costs with hopes that insurance will pay them more, but they end up settling for less. Seems like a major fuck up on the part of the surgeon's office though.

I know there is a huge difference between surgeries completed in a real hospital vs a surgery center in terms of how much they can bill your insurance.

You may need to work with the hospital on a payment plan or reduced bill (which can be done with the assistance of an attorney).

[Txagq8]

Whether it’s $36,000 or $366,000 the charge is ridiculous.

I seldom advise people to willfully refuse to pay just debts but when it comes to medical care, then yeah. Eventually they will get tired of trying to collect a bad debt and in my case I’ve never seen a hospital or medical care provider report to a credit bureau.

Was it a day surgery type admission? If so some research ought to tell us what the Medicare or Medicaid allowable is. You could go so far as to offer to pay that and borrow it from a bank/credit union if you need to.

I don’t have a copy of my itemized bill or Tricare explanation of benefits in front of me but I remember some of it. Between surgeon, his clinic, radiology, lab, hospital, and anesthesiologist the total billed was $53K. The Tricare allowables totaled $19K so that’s what they got. Iirc the surgeon, his practice, the labs, and the anesthetist were about $9200 and that left $9800 for the hospital and the cost of the implant was buried in hospital charges.

I know this is stressful. Take a deep breath. Your goal is to ensure people are fairly compensated but you are dealing with a screwed up health insurance plan exacerbated by the error of a third party in not checking before they sliced.

If you are able to, I would extend the offer (probably via a lawyer) to settle the debt in cash at a price roughly equal to the Medicare/Medicaid allowables that the hospital is forced to take from those cases.

Cash speaks volumes. Most hospitals are gladly going to take something rather than nothing. But if they won’t budge, simply refuse to acknowledge the debt. You were operating in good faith that your insurance carrier was covering everything but a small amount of copay.

Just my opinion. I have little sympathy for health care providers. If they priced their goods and services based upon cost to deliver those services plus a reasonable profit margin…..that would be fine. But when two Tylenol tablets are $150 each because you’re in a hospital bed and can’t go to Walgreen’s….well, their business model needs work. It really wasn’t this dicked up prior to the govt involving itself in health care.

[AverageBloke]

I paid 20k cash for my surgery including implant and hospital fees.

The number 366k doesn’t even make sense to me.

[Alex258]

Alex258,
Who was your surgeon and what insurance do you have? I would think any attorney would jump at a chance to go after this. Why was that not your case?

Even though I have the proof of Blue Cross/Blue Shield, they first used American Health to do the initial intake of which American Health said yes I did need the surgery and BCBS slipped up in letting my Doc's office approve.....this bit of proof no lawyer felt that I had a strong case. Won't name the surgeon. They've been behind me and they too are dumbfounded of what took place. Haven't asked me for a dime since 20 months ago or so. All I can do now is see if cash will bring the amount down. I'm just another number caught up in the system. I am on Medicare now so won't have these issues if I need a replacement etc.

[JohnHC]

I had two surgeries pretty much back to back ( April last year then in June ) the insurance refused to cover the surgeries ( shocker there ) and my bill total on both surgeries was only about $187,000. I don't know how they would come to $366,000 so yes I would try to get a lawyer involved. Contact the implant manufacturer, they might be able to help. AMS ( Boston Scientific ) has a legal department that might be able to help if you got one of their implants. I appealed my insurances denial and gave them the info Boston Scientific gave me, a letter from my Dr and a letter from me detailing everything up to needing the surgery and just got a response yesterday that they were reversing the denial and going to pay my claims ( my denial was because the surgery is listed in my exclusions - something I was never told, even when I called to check coverage they didn't say anything about exclusions and no exclusions show up in the computer on my policy ). So yes you can fight it, you might win without a lawyer, but at that ridiculous amount I would involve one if I could. Good luck and I hope you prevail