Cigna rejected my claim - advice please!

[steve98689]

I live in Illinois and I have good Cigna insurance through my employer. In January to May 2019, my wife had IVF treatments in order to have a baby. In January, the doctor's insurance manager told us that our lifetime max was $10,000 and we will probably go over it. So when our balance reached $7,924, they told us to pay the last 2 bills out-of-pocket and submit the claims later to Cigna. That sounded reasonable at the time but now I'm learning the hard way that is not the right approach. I've called Cigna several times and one rep told me that they should have billed Cigna first and then billed me the remainder. Anyways, the last 2 bills were (1) $3800 PGS genetic testing on 2/10/2019 which is considered elective so it was rejected, and (2) $4000 frozen embryo transfer on 3/14/2019 which should be covered. I sent the claim form on 6/18/2019 and Cigna received it on 6/24/2019. I called back and found out I was rejected, because the claim was filed over 90 days which is the filing deadline for an in-network doctor. I've never submitted a claim before and did not know about this rule. The reason I filed the claim so late is because June is when my wife was completely done with all her IVF treatments. I sent an appeal form on 8/12/2019 for the unused insurance balance of $2075 but was rejected again for the same reason. The rejection letter says I can "ask for an independent, external review of our decision". So here are my questions: Am I on the hook for this? Was I supposed to know about the 90 day deadline? Is the doctor's office at fault? Will an external review be lenient because it's the first claim I've ever done?

 

[cbg]

Am I on the hook for this? If the independent external review is unfavorable, yes. You might be able to negotiate a discount or a payment plan, but you will be responsible for the unpaid portion.

Was I supposed to know about the 90 day deadline? Yes. I tell people and I tell people and I tell people, it is YOUR responsibility to call the insurance company yourself and find out how the claims are supposed to be submitted and what is covered. It is NOT the doctor's office's responsibility to know the details of the insurance plans for each of their patients.

Is the doctor's office at fault? Depending on what type of insurance you have (I don't mean CIGNA, I mean HMO/POS/PPO.HDHP) the doctor's office may be responsible for submitting the claim. However, you are responsible for knowing what is covered and to direct the doctor's office on what is required, not the other way around. So while they may have given you incorrect information, it isn't going release your legal responsibility for the bills. If you talk to them about it, they may be willing to adjust their bill under the circumstances. They are not required to.

Will an external review be lenient because it's the first claim I've ever done? No.

 

[BuyLowSellHigh]

I have personal experience with an in-network IVF doctor. There was a charge that they didn't want to bill the insurance company. I found out later that the reason is that there is an agreement with the insurance company as to how much they will pay for the procedure. I told the doctor's office that the pricing agreement was between the doctor and the insurance company and had nothing to do with me. Eventually they billed ($200 doctor's price) and I paid the much lower cost ($10 insurance price). So by not billing charges you are paying whatever price the doctor wants to charge rather than the negotiated insurance rate between the doctor and the insurance. In the future whether you have any benefit amount remaining or not you have to make sure the doctor bills all charges because you may still get a discounted price.