Am I being misled?
I’m seeking treatment for my varicose veins and chose a specialty clinic that’s in-network for both the facility and the doctor. I attended an initial consultation, ultrasound, and a follow-up appointment. The clinic submitted the treatment to my insurance, which got approved, but for a facility that’s located out of town.
I was then informed that my specific insurance is the only one they accept that doesn’t cover the procedure at my local clinic. When I contacted my insurance company, they assured me that the procedure is in-network and will be covered, confirming this with four different agents.
However, the clinic insists that my location isn’t accredited. The insurance representatives stated this shouldn’t matter since it’s covered under my plan. During a three-way call with both parties, the clinic kept repeating their stance almost verbatim, leaving the insurance representative confused and me even more puzzled. We even brought in a fourth person from the insurance company, who seemed completely lost and mentioned he couldn’t access the contracts.
So, who’s telling the truth here? Why does my insurance say it’s covered while the clinic denies it and won’t even consider submitting a pre-approval for my local facility? Can anyone help clarify this situation?
It sounds like a frustrating situation with a lot of moving parts, and it can be difficult to navigate the complexities of insurance and healthcare facilities. From what you’ve described, it appears there may be a miscommunication or misunderstanding between the clinic and your insurance company regarding coverage and accreditation.
Here are a few steps you might consider taking to try to clear up the confusion:
Request Written Confirmation: Ask the clinic for a written explanation of why they believe the procedure isn’t covered at their location. Similarly, get written confirmation from your insurance provider stating that the procedure is covered in your town clinic.
Check the Insurance Policy: Review your insurance policy or benefits documentation. It may contain information regarding coverage for treatments at accredited facilities versus non-accredited ones.
Accreditation Details: Ask the clinic for specific details about why they consider your location not accredited. There may be specific criteria or guidelines that you can verify.
Talk to a Supervisor: If possible, escalate your concerns to a supervisor or a higher-level representative at both the clinic and the insurance company. They may have more authority to resolve the issue.
Contact the State Insurance Department: If you’re unable to resolve the issue after these steps, consider reaching out to your state’s insurance department for assistance. They can provide guidance and help mediate the situation.
It’s difficult to say definitively who is “lying,” but it does seem like both parties may have valid perspectives based on their interpretations of the contracts and regulations. Document all your communications thoroughly, as this will be helpful if you need to escalate the matter further. Good luck!