Insurance Nightmare

[Ronn1708]

Well I had my revision on 2/13/24. I had several conversations with my insurance . I got mixed messaging about it had to be pre approved and that it wasn’t required because it was out patient surgery. They then sent in writing that it was a covered service based on the CPT codes. Insurance then notified my Doctor that the service was a covered expense. I filed a request with the hospital asking for cost of the procedure. I then had to provide all my information including name, social, insurance id number. They ran the info through and sent me a notice that the procedure was covered 100% after deductible was met. They further stated my deductible had already been met so it was covered 100%.
Well I had my surgery on 2/13/24. I was notified on 2/21/24 that the service was denied because it wasn’t a covered expense (sexual dysfunction is not covered) and I didn’t get prior approval.
So now I’m in the second appeal process.
I also read on the insurance app that prior approval is not a guarantee to cover the services approved.
I got a bill from hospital today showing I owe $0.00 but over 42k is pending insurance.
I’ll tell you that eight days post surgery is a terrible time to get into all this drama. Trying to recover and then placed under the load of financial distress. I told them I can’t go undo the surgery and give it back.
The EOB shows I will owe 23k because the hospital didn’t get preapproval. The original bill was 119k but reduced because of insurance agreements.
Please Say a prayer for me and my mental health and for my finances!

[JohnHC]

I know your pain as I'm in the same boat right now. My first implant done in April last year was defective, revision in June. It has failed so I need a 3rd one placed but right after my revision the insurance said nope were not covering it after they informed us it was.... So yeah 42k is what I owe the hospital, and the Drs office won't do the revision unless I pay upfront because of insurance hosing them over.. even if I pay the Drs fee of $3500 there's no guarantee the hospital will let him do it since I owe them so much.

[Bigdave]

That should be criminal.
If they pre-approve a procedure they shouldn't be able to reverse it after the fact.

My prayers are with you both.

[LastHope]

If you don't have Medicare, this procedure will not be covered even after getting pre authorization. This is not new. Can you get a Malleable implant when you get your next revision?

[Ronn1708]

Well I’ve had numerous revisions and insurance has always covered it. This is the first time under our new company insurance that this issue has came up. I have not considered another type implant. I’ve only saw one guy at the gym with the Malleable and it looked very uncomfortable and unnatural in appearance. I mean it would be a hard dick but I got that now along with a huge bill.

[easymoney]

Curious if you asked him the brand and how long he had the mallabble or are you assuming it was a mallabble just by the look of it ..

[Txagq8]

That should be criminal.
If they pre-approve a procedure they shouldn't be able to reverse it after the fact.

My prayers are with you both.

No, it’s not criminal. But is is actionable in civil court.

Sue the insurance carrier. They don’t get to change their mind. If they said “go ahead, it’s covered” they do not get to change their mind.

And if their telephone center said it, evidence can be found during discovery. “Calls may be recorded for quality purposes.”

But it won’t get that far. Insurance companies hate oaying claims but they hate being dragged thru the mud in front of a jury which might award a whole lot of punitive damages even more.

If you still owe anyone, do not pay them. If you have paid them, send them a letter that the payment to them was an advance instead of a total settlement pending insurance settlement and they were still subject to the insurance allowable reimbursement.

Then see a lawyer. Sue. I suspect they’ll trip over their own legs in a rush to settle.

File complaints against the company with state board of insurance. Even if they don’t cover penile prostheses for sexual purposes, the company probably pays for them in other situations. They authorized yours. End of discussion.

[Ronn1708]

Well I have not paid anything. I don’t have the money to pay. I’m just hoping they will honor their word and do what they said they would do. I hate being in the situation but it was really devastating to find out 8 days post op while trying to recover.
Time will tell. I’ve talked to the hospital twice since I found out the insurance denied it. They said they had not yet been notified and it was showing pending
Maybe that’s a good sign.
Thanks again

[OregonStrong]

But if you have gender dysphoria and want a sex change they will always cover it, regardless of insurance, including breast implants! Totally not fair.

[Alex258]

I'm on my 2nd appeal from approved surgery back in Jan 2020. Just retained a lawyer. My docs office hasn't asked me for a penny and is helping me with this Bad Faith way with my insurance company.