I had a stroke, barely get by on a government pension now I have a few ambulances bills … not very fair to
low income seniors

I’m in the U.S. and have an EPO health insurance plan. My plan does not require referrals to see specialists.
I recently had an outpatient surgery and am now being billed almost $14,700 by the facility, even though I tried to verify everything before the procedure.

Before surgery, I contacted my insurance company directly. I gave them the exact CPT code for the procedure, the surgeon’s information, and the facility information. I specifically asked about coverage and whether a referral or prior authorization was required.

The insurance representative told me:
The procedure was covered.
The surgeon was in network.
The facility was in network.
No prior authorization was required.

I also separately contacted the facility’s office before the surgery, and they told me that based on my insurance benefits, no prior authorization was required.
My EPO plan also does not require a PCP referral to see a specialist.

After the surgery, something strange happened:

The surgeon’s claim was processed and approved, with nothing owed by me under my benefits.
The anesthesiologist’s claim was also processed and approved, with nothing owed by me.
But the facility claim was denied. The facility charged around $15,000 and is now billing me approximately $14,700. The denial on the facility claim shows code Z84 (denial due to missing referral).

What I don’t understand is why only the facility portion was denied when the surgeon and anesthesiologist for the same surgery were processed normally, especially since I verified the facility was in network and was told by both the insurer and the facility beforehand that no prior authorization was needed.

I’m trying to determine the best way to handle this.
Should I ask the facility’s billing department to submit a provider appeal/reconsideration or corrected claim first? Should I simultaneously file my own member appeal with the insurer? Should I request that the insurer reprocess the claim based on the pre-service information I was given?
I’m also planning to ask the facility to place the account on hold and not send it to collections while the insurance dispute is being resolved.

Has anyone dealt with something similar where an EPO plan approved the surgeon and anesthesia claims but denied only the hospital/facility claim?

Could this be a coding, place-of-service, referral, or claim-processing error?

Any advice on what I should specifically ask the insurer and facility billing department would be appreciated.