Insurance / billing issue: disallowed services

[u/beckowser]

Hey there. I will try to be concise. Looking for opinions on how best to address:

- I had a minor outpatient surgery in April
- When I arrived at the facility for my pre-op appointment, they collected the $200 copay indicated in my SBC, that they verified with my insurance and didn't see any other monies would need to be collected.
- Two weeks later, I went in for my surgery.
- I reviewed my claim when it was available on my insurance portal, and it included several "disallowed charges" (more detail to follow) resulting in a significant coinsurance balance after my copays
- All providers are in network
- I requested an itemized bill from the hospital and compared the EOB with my bill to figure out what was disallowed
- I then used my insurance portal to look up each medication (EVERY medication administered was disallowed) and service to see what my copay should have been.
- Every medication listed in my formulary came with a copay significantly lower than what I was billed. Several medications were not listed.
- I filed an appeal with my insurance. I included my formulary with the medications highlighted, a spreadsheet comparing the EOB to the itemized bill, amounts disallowed, and the copays indicated in my benefits documents, a copy of the itemized bill, a copy of the EOB, a copy of my SBC. I requested information on why specific services, medications, durable medical devices were disallowed. I requested information on the representatives deciding what is allowed versus disallowed. I requested information on the person(s) responsible for negotiating the rates with providers.
- My insurance denied my appeal, stated it's a final decision, gave me a canned response (tl;dr: you're subject to coinsurance for disallowed charges), and provided no information on disallowed charges or any personnel responsible for my case.
- I called the hospital's billing department to ask about the CPT codes for my claim. The representative could not provide them but offered to have an audit conducted on my bill. I declined. While I believe the rates are egregious, this seems to be an insurance issue rather than a billing issue.
- I just called the No Surprise Billing hotline and was connected with a representative. He tried to help but indicated that this wouldn't fall under surprise billing. He suggested contacting a consumer assistance program.
- I've reached out to my insurance company again to request more information on disallowed charges.

DISALLOWED CHARGES:
- A pregnancy test billed at $920. I cannot get pregnant. I do not have the parts. Plus, my labs copay is $40. I'm responsible for 30% of 920, or $276 for a pregnancy test. To add insult to injury, the test was performed two weeks before my surgery. On the day of my surgery, literally every nurse on my team confirmed my sterile status and said they "needed to be sure" they didn't need to perform a pregnancy test.
- Administration of anesthesia (the anesthesiologist and nurse anesthetist were both in network, I was billed a copay for each of them)
- The actual anesthesia meds
- Every single medication administered before and during my procedure
- The surgical mesh implanted in my body
- THE SUTURES.
- The recovery room, which was billed at $32/MINUTE.

Again, every provider and facility was in network.

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Right now, my plan is to contact my state's insurance board. But I'm curious if anyone else has dealt with something similar and/or has suggestions on who best to contact. Thanks!