Insurance company denied coverage

What is the name of your state? PA

Hi,

I was told by my Health Insurance ( thru employer ) company that my co-pay for out-of-plan providers would be 20 %. Since their coverage is not very good in the area which i live we chose an out-of-plan ob-gyn practice and hospital for my wifes pregnancy. Now they have sent me a letter saying that they are denying coverage for hospital charges because it was not pre-authorized by them. The letter also says it is the members responsibility to seek pre-authorization for the delivery.
Their handbook and website however say that pre-authorization should be initiated by a medical practitioner and i assumed that the doctors office would have taken care of it.
Is this denial of coverage fair ? Can anything be done ?

Thanks in advance

[cbg]

Did you tell your provider that preauthorization was needed? Did you ask him to call?

During our first visit to the doctor we had presented our insurance cards which they photo copied, and the lady at the office had called the insurance too and told me about the co-pay details.
I do not have much experience with the health system in the US and so i assumed that pre-authorization and other things for the delivery will be taken care by the doctors as the insurance companys manual said. I dont think i told them specifically that preauthorization was needed for the delivery.

Originally Posted by cbg

Did you tell your provider that preauthorization was needed? Did you ask him to call?

[cbg]

I suspect you are out of luck.

On some plans, you have complete and total responsibility for seeing that pre-auths are done. In other plans, the responsibility lies with the doctor; however, YOU are responsible for making sure the doctor knows which kind of plan you are on. It's not enough for them to know that you are on, say, Blue Cross Blue Shield, because BCBS has multiple plans, not all of which are handled the same.

If you did not tell the doctor that you needed him to call for a pre-auth, he had no way of knowing that he needed to do so. Your insurance card would NOT be enough for him to know that.

If the plan says that pre-auth is needed and pre-auth is not obtained, you are on the hook for the bill.

Does that mean that their are plans which require no preauthorization for procedures ? I still cannot believe that my not asking the doctors office to preauthorize a delivery has cost me 10k. And i have come out of this looking like a complete idiot.

[cbg]

Yes, there are plans which require no pre-auths and there are plans in which the member, not the doctor, has responsibility for calling. The doctor does not have any way to know that your plan requires him to call for a pre-auth unless you tell him.