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Doctor visits, prior authorization, and headaches

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  • Doctor visits, prior authorization, and headaches

    I have an of situation that I'm not sure what to do with. It's not strictly IC related, but this is the best forum I've found anywhere, so I'm going to ask y'all.

    My GI (gastroenterologist) has been working with me for long-standing RUQ pain. I'm at high risk for cholangiocarcinoma, so it's a big concern when I have unexplained pain in that area. He referred me to another doctor at another hospital for an ERCP, cholangiocarcinoma, and FISH analysis to dilate my structured bile ducts and look for cancerous or precancerous cells. This was back in February. We got a letter from my insurance staying that no prior authorization was required.

    The other hospital's scheduling department called me in March to schedule an office visit. I asked why I needed an office visit when I'd been referred for an endoscopic procedure, and the lady who'd called me told me that I couldn't have an endoscopy without first having an office visit with the doctor. So I scheduled the visit for June.

    At the visit, the doctor told me he wasn't the one who does ERCPs, but that he'd schedule me for one with the doctor who does them. He also sent me for labs.

    In July I got a call from scheduling to set up an MRI, which they said the doctor I saw in the office had requested. My insurance pre-approved that, despite the fact that I could have that done in network, and wasn't due for an MRI until October.

    Last week I got a notice from my insurance that they won't pay for the office visit because it wasn't pre-approved. They're algae refusing to pay for the labs, which the other hospital bills as a five minute office visit with a doctor I've never seen.

    I'm planning to appeal the denial, based on the schedule telling me that the office visit was required and the doctor whom i saw on the "required" visit ordered the labs, presumably because he needed them before I got the ERCP. That was what I thought at the time, but I doubt my insurance will want to pay based on that.

    I'm also wondering about asking the other hospital to write off the fees for the office visit and land, since it was their scheduler who lied to me and told me I had to have the visit, and since their doctor should have known that the labs were not required for the procedure that I'd been referred for. I don't know how that's going to go.

    Anybody have any thoughts, wisdom, insights, or advice? I'm running out of ideas here.

    The bill is enough that il mid the money if I end up paying it, but not enough that it puts my finances into serious jeopardy. Mostly it's the principle of the thing.