Am I being misled?
I’m seeking treatment for my varicose veins and chose a specialty clinic where both the facility and the doctor are in my insurance network. I attended the initial consultation, ultrasound, and follow-up appointment. The clinic submitted my treatment to insurance, which was approved, but for an out-of-town location. I then learned that my specific insurance is the only one they accept that doesn’t cover the procedure at my local clinic.
However, when I contacted my insurance company, they confirmed that it is indeed in-network and that the procedure would be covered. I’ve checked this with four different representatives. The clinic, on the other hand, insists that my local facility isn’t accredited. The insurance agents maintain that accreditation isn’t relevant since the procedure is covered by my plan.
We even had a three-way call, during which the clinic repeated their position almost word-for-word, leaving the insurance representative confused and me feeling lost. When we brought in a fourth representative from the insurance company, he admitted he couldn’t assist further and mentioned he couldn’t access the “contracts.”
Who’s not being truthful here? Why does my insurance say the procedure is covered while the clinic insists it isn’t, refusing to submit a pre-approval for my local location? Can someone help clarify this situation?
It sounds like a frustrating situation, and it’s understandable to feel confused when you’re hearing conflicting information from both the clinic and your insurance provider. Here’s a breakdown of what might be going on:
Credentialing and Accreditation Issues: The clinic may be correct in that your particular insurance plan requires certain facilities to be accredited for specific procedures. Even though your plan covers the procedure at their location, if the clinic itself isn’t recognized for that treatment locally, they may not be able to process it at that facility. Sometimes, contracts between insurance providers and clinics specify conditions that are not immediately obvious.
Insurance Verification Process: The insurance agents you’re talking to might be looking at the coverage details broadly and can see that the procedure is covered under your plan. However, they may not have access to the most up-to-date information regarding which facilities are accredited for specific treatments, leading to a disconnect.
Training and Information: Different agents may have varying levels of training or information regarding your specific case. This might explain why one agent can confirm coverage while others are uncertain or confused.
Claims Submission: The clinic may be discouraging submission to your local facility due to a history of claims being denied or issues with reimbursement in their business relationships with the insurance provider.
Here are some steps you can take to further clarify the situation:
Request Documentation: Ask the clinic to provide written documentation explaining why they believe the procedure can’t be done at their facility. This may help clarify whether it’s based on a legitimate accreditation issue or something else.
Get a Third Opinion: Consider asking another clinic that specializes in vein treatments for their perspective on the accreditation issue and to see if they accept your insurance.
Contact Your Insurance Again: Try to speak with a supervisor or a claims specialist who might have more insight into why there’s a discrepancy.
Consider an Appeal: If you feel confident that your procedure is covered and the clinic is still denying it, you can inquire about the process for appealing their decision with your insurance provider.
Finally, remain persistent with both parties. It often takes time to find a resolution, especially when dealing with the complexities of insurance and healthcare. Good luck!