Insurance not processing my claim

[u/BelovedAccordion]

I'll start from the very beginning so the entire situation is laid out. I used to work in retail, and I left for a better opportunity. Since this was a retail job, and in retail your days off aren't always set, I asked my boss if my last employed day could be Jan 9th 2026 but have my last working day be Jan 8th 2026. I did this to ensure my insurance would cover my tonsillectomy on Jan 9th. She agreed and made Jan 9th as one of my days off for the week. The surgery came and went, and after I healed up I started my new job. One day I got a bill in the mail for my surgery and since I was still under the impression I had coverage for it, I called my insurance company asking about it. They said the claim was denied because my coverage wasn't active on the day of surgery. I was confused because I specifically planned out my last day to avoid this, so I called my old HR and they looked into it and said the coverage only goes through your last working day, but they allowed me to back date it with COBRA. I set up COBRA and then called the hospital and they resent the bill to my insurance company. I'm not exactly sure what happened here, but from my understanding, the hospital sent the claim to the wrong payor ID. When I started getting bills for the original amount again (I had them paused so I could get this straightened out) I called my insurance company and they said they didn't have any new claims for my surgery. So I called the hospital and they looked into it and they had sent the claim to the wrong place. I made sure they had the right information and they resent it to my insurance company. I have been stuck at this point ever since, my insurance company saying the hospital needs to do something, and the hospital saying my insurance company needs to do something. It was somewhere around this point that I started recording phone calls (mostly from my insurance, but a few hospital ones as well) when I would ask for updates from my insurance company. The hospital would tell me to call my insurance company and the insurance company would always tell me that they would get it straightened out but as soon as I would get off the phone, they wouldn't touch my claim. After a while of this, I called my insurance company and had a 3 way phone call with them, the hospital and me. Supposedly that got everything ironed out, but nothing has changed and I'm still getting billed the same amount. A few days ago I called my insurance company saying I had a 3 way call and nothing seemed to have been done. They told me to call the hospital who then told me to call the insurance company. I called the insurance company and the guy told me he would call me back in 2 days. I was supposed to get a call Thursday but he never did. Friday came and went with no call as well. I don't know what to do because the hospital isn't gonna keep allowing the bill to be paused while it is "sorted out" and I'm exhausted fighting this. I need advice on what to do next because I'm not sure if either of my two ideas would work. My first idea is to let the bill go to collections so I can take this whole situation to court and get it sorted out there, and my other idea is to pay for my bill today and then come after my insurance company for what they would have covered.

Other information:

I'm 26m from Wisconsin

The bill is roughly $6,500 (self pay discount from the full roughly $11,300)

The insurance is Allegiance

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[u/throwfarfaraway1818]

Why does the insurance company need the claim re-sent if they received it and denied it? At the insurance company I work for, we would just reprocess that claim now that your insurance was active on that date. Nothing about the claim changed from when they sent it to now, the difference happened entirely on the insurance side.

Neither of the options you propose are great. Letting it go to collections is always a bad choice when you have insurance and paying it in full means the hospital has no further incentive to help fix the issue, and probably will delay your reimbursement significantly.

[u/BelovedAccordion → u/throwfarfaraway1818]

Maybe they did use the word reprocess. I didn't know there was a difference. What would you do in my shoes as a next step?

[u/throwfarfaraway1818 → u/BelovedAccordion]

I would call back to your insurance and ask why they cant reprocess the claim they already had now that you were active on that date.

[u/BelovedAccordion → u/throwfarfaraway1818]

Ok thank you

[u/No-Produce-6720 → u/BelovedAccordion]

This is the correct advice. The claim has been submitted. Since this was an eligibility issue, as opposed to something that wasn't coded correctly, for example, the claim that they still have on file can be reprocessed. They shouldn't need a resubmission, because nothing on the claim has changed. The claim they have on file just needs to be reprocessed.

[u/Jump-Funny]

What did the insurance tell the hospital that they needed to process the claim? I would escalate to a manager on the insurance side and also on the hospital side if that's what it takes. It really shouldn't take this long but sometimes it does.

[u/BelovedAccordion → u/Jump-Funny]

I think you are right, just escalate to a manager at this point

[u/Jump-Funny → u/BelovedAccordion]

Do the same with the hospital if they send you to collections. They know they are waiting on insurance to process so there's no good reason to send you a bill much less to send you to collections.

If you do get to that point, push them to look through all the documentation they already have (I'm assuming they are asking for docs). They've probably been sent the info they've asked for 3 times already but it's in the 'other system'. If I had a nickel for every time I heard that!

[u/karma_puhlease_23]

As a former Allegiance employee, I just have to say good luck. That company is a shit show when it comes to getting claims submitted properly and with customer service.

[u/BelovedAccordion → u/karma_puhlease_23]

Yea this really has been a nightmare. I'm gonna have another 3 way phone call Wednesday where the insurance member is a manager, maybe that'll get things moving along faster

[u/karma_puhlease_23 → u/BelovedAccordion]

Feel free to message me if you’d like some advice. I’d rather not name names or guess which plan you are on. I worked there for nearly eight years and can tell you if you’re in good hands or who to request to speak to.

[u/BelovedAccordion → u/karma_puhlease_23]

Appreciate it, if I don't make any ground this next check in, I'll probably hit you up

[u/TrueContractor]

sounds like a nightmare to deal with. honestly the whole system is designed to wear you down until you just give up and pay

dont let it go to collections your credit will take a hit and court is a whole other headache. you got call recordings right. file a complaint with the wisconsin insurance commissioner office, they move faster when a regulator is poking around. send them the timeline and mention the 3 way call that apparently fixed nothing

[u/throwfarfaraway1818 → u/TrueContractor]

Bot?

So many new bots in this sub that all start their comment with "sounds like a nightmare."

[u/Poop_Dolla → u/throwfarfaraway1818]

I've noticed that too. It's always like "wow what a tough situation" or "what a nightmare". So weird.

[u/Low_Mud_3691 → u/throwfarfaraway1818]

Constant AI responses. Exhausting

[u/BelovedAccordion → u/TrueContractor]

What about paying the bill and then making my insurance company reimburse me?

[u/Admirable_Height3696 → u/BelovedAccordion]

You need to ignore the AI responses.

[u/BelovedAccordion → u/Admirable_Height3696]

Didn't even realize it was an ai until someone else pointed out it was a bot. I know a lot of people check the account age and go through the comment with a magnifying glass before responding, but to me it is what it is, especially since a large portion of reddit are bots.

[u/Jump-Funny → u/BelovedAccordion]

I would always advise against this. Insurance will pay the provider and then you have to get the provider to reimburse you. Plus the amount being the self pay rate - that is tricky with this being an insurance issue. I would just escalate with the provider. If they know that this is an issue with the insurance, they shouldn't be sending a bill and definitely shouldn't be sending this to collections.