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HMO precertified my surgery but revoked authorization AFTER it was done

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Junior Member

Okay, so on March 24th I had minor outpatient surgery. (Will leave out the details as it's a bit embarassing, plus probably TMI for you all. :p) The doctor's office got authorization to perform said surgery from my health insurance provider, CareFirst BlueChoice and that costs would be paid in full.

A few weeks AFTER the surgery, I'm told that CareFirst decided that the condition was pre-existing and should not have been covered in the first place. They sent me "explanation of Benefits" forms with "This charge has exceeded the plan allowance for this service. This non-allowed amount is included in the member responsibility amount, and the provider may collect the non-allowed amount from the member." The total charges from my doctor's office and others (e.g., anesthesia doctor) that CareFirst expects me to pay are about $2,350.

The doctor's office has a precertification number and record of phone calls made to CareFirst saying that my surgery would be covered. According to my insurance plan, outpatient surgery with referral/authorization (and even out-of-network) has 0% Coinsurance. It wasn't until after the surgery that CareFirst decided to change their mind (!!!!) and not cover 100% of the amount.

I am royally pissed off. :mad: This has to be illegal on some level - CareFirst can't say one thing and then change their mind after the surgery was done! I specifically said to the doctor that I would not have the surgery if it wasn't 100% covered (and in that case, I joked that I would do it myself and end up in the ER, where CareFirst would have to pay for all of it. ;))

I feel like simply writing a letter to CareFirst isn't going to do anything at all, if not give them more time to stall and continue to deny my claims. Is there something in the Virginia State Code where I can get some sort of backing and more ammo against them?

Any help would be much appreciated. Thank you!


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