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What did I do wrong? Exclusive Provider Organization & preauthorization question

17th February 2016

Reader submitted question below. Please reply if you can help.

This is the first time I’ve ever had to deal with substantial medical bills, so bear with me. I’m attempting to figure out what exactly was my fault, the doctor’s fault or the insurance company’s fault.

Three months ago, I was in a bad accident, which included broken bones. I was referred by the Emergency Department to hospital’s outpatient orthopedic clinic for follow-up care. I called them, I gave them my insurance information, they recommended a doctor, and I booked an appointment. I checked the provider directory and called the insurance company to make sure the doctor was in my network and he was.

I’ve had three appointments since then, and my insurance’s website updated my claims section. They covered the office visit, but they did not cover treatment of fractures, which was placed under alternative codes. I called the insurance company to obtain an explanation. They stated that they consider the code they used for fracture treatment (23500) as a surgical procedure, and since surgeries require preauthorization and I wasn’t preauthorized, they will only over 50% of that amount (or up to the contracted amount) since it was medically necessary.

1) I thought I was already being meticulous by reading over my contract and benefits, and making sure providers were in-network. Was it my fault for not calling the insurance company prior to seeing the ortho? I was under the impression that it was an office visit, which should be fully covered except for a co-pay/deductibles and such. I had no idea that what I was doing was getting an office surgery, but perhaps I just wasn’t meticulous enough.

2) Was it the doctor’s office’s fault for not getting preauthorization? When I had a shoulder MRI, they got preauthorization for that. From my internet research, the 23500 code seems to be a typical code used for “global fracture care” and is considered a surgical procedure…don’t doctor’s offices need to get preauthorization for such procedures? Should I call them for help and what can I say?

3) Or is this just my insurance company screwing me over? It does say that surgeries need preauthorization in my contract, so it doesn’t seem I have much recourse. They told me I can file a grievance, but I don’t know what my stance would be.

4) As an aside, I got balance billed by the ED doctor, since she wasn’t in my network, sigh (even though the hospital is). Is this worth calling up the hospital to get it reduced via discount, like if I pay up front? I don’t qualify for any financial assistance, though.

I should add that my visits consisted of taking x-rays, seeing the doctor for 10 minutes for explanation of said x-rays, and advice on what I can do to improve, like physical therapy.

According to documentation, the Plan Type is EPO. It has a $0 deductible, and does not require a referral or permission to see a specialist. What is an EPO plan? EPO stands for “Exclusive Provider Organization” plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits.

The ED doctor was out-of-network. That I’m willing to let go of. The ortho is a provider within my network, though. I looked him up in the directory and called the insurance company to make sure prior to seeing him, and that I would be covered under my plan if I went to visit him.

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