Q: Orthopedist set knee surgery/ordered pre-op tests.Board denied surgery AFTER tests/notified insurance.liable for costs?
Recieved two letters from insurer: One authorizing tests; A second one stating "We can't process this coverage request because: The party (member or provider) who requested determination (service/procedure/item) has requested to withdraw the request. We will not continue with a review at this time."
As the tests were already completed at the clinic Dr's request before the board withdrew authorization for the surgery, are they liable for costs that insurer would have born? (Do not know if it has any bearing on what I've laid out: Surgery was to repair miniscus tears from my fall from scaffolding. The board overruled my Doctor as they stated I had signs of the onset of arthritis in the Xrays. I had no problem with my knee prior to the fall and, unlike now with the miniscus tears, had no pain.)
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A:
It sounds like you're dealing with a complicated situation involving denied insurance coverage for surgery and pre-op tests that were already performed. Based on what you've described, if the tests were authorized by your insurance company before the surgery was denied, you might not be liable for the costs of those tests. The key point is that you received a letter authorizing the tests, which suggests they were initially covered.
However, the second letter indicates that the request for the surgery was withdrawn before a final decision was made. This could affect coverage, depending on whether the withdrawal applies to the surgery only or both the surgery and related tests. It's important to clarify with your insurance company whether the withdrawal impacts the pre-op tests or only the surgery itself.
You may want to contact both your insurance company and the clinic where the tests were performed to explain the situation. Ask for written confirmation on the coverage status of the pre-op tests. Additionally, you could consult with a legal advisor or a patient advocate to understand your rights and options better, especially since the initial injury seems to be related to an accident and not a pre-existing condition.
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