Hi folks,
We found out last year that my wife has a cardiac issue that we should have out children (5 & 7) screened for. Upon initially meeting with an in-network pediatric cardiologist, one of our children was ruled out and the other needed a cardiac MRI to confirm she may have the same issue.
The cardiac MRI was set up at the regional hospital the specialist was affiliated with. Both are in-network for my health insurance plan (CIGNA).
I didn’t give much thought to the precertification process since under our plan, if the provider is in-network, they are responsible for any precertification work.
So we went ahead with the procedure, everything went fine, diagnosis was confirmed (it’s more of a condition to watch)… the day after the procedure we received a letter from CIGNA that stated they only approved one portion of what was requested but did not approve the other as enough information wasn’t provided to confirm medical necessity. The letter was dated one week prior to the procedure, not sure why it took so long to get to us. In either case, no one at the hospital mentioned anything about this and based on what they billed for, they went ahead with the whole procedure (the MRI was approved, another imaging study to look at vascular structures wasn’t).
CIGNA has been holding the claims for about 2 months working with the hospital on getting things sorted, they paid the claim for the portion approved but have now denied the claim for the other portion. In the EOB it has that we would be responsible for the portion not covered by the plan but in the original letter, CIGNA noted that in general, an in-network provider can not bill us for services not covered unless we agree to do so in writing (again nothing specifically signed here… although at admissions we signed the digital screen without getting an opportunity to review anything we signed).
Has anyone had something like this happen before and how would you navigate? I’m worried I’ll get a bill for $12k but I think it’s the hospital’s issue to sort out with CIGNA.
Edit- in Pennsylvania
submitted by /u/davidh676
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Hi folks, We found out last year that my wife has a cardiac issue that we should have out children (5 & 7) screened for. Upon initially meeting with an in-network pediatric cardiologist, one of our children was ruled out and the other needed a cardiac MRI to confirm she may have the same issue. The cardiac MRI was set up at the regional hospital the specialist was affiliated with. Both are in-network for my health insurance plan (CIGNA). I didn’t give much thought to the precertification process since under our plan, if the provider is in-network, they are responsible for any precertification work. So we went ahead with the procedure, everything went fine, diagnosis was confirmed (it’s more of a condition to watch)… the day after the procedure we received a letter from CIGNA that stated they only approved one portion of what was requested but did not approve the other as enough information wasn’t provided to confirm medical necessity. The letter was dated one week prior to the procedure, not sure why it took so long to get to us. In either case, no one at the hospital mentioned anything about this and based on what they billed for, they went ahead with the whole procedure (the MRI was approved, another imaging study to look at vascular structures wasn’t). CIGNA has been holding the claims for about 2 months working with the hospital on getting things sorted, they paid the claim for the portion approved but have now denied the claim for the other portion. In the EOB it has that we would be responsible for the portion not covered by the plan but in the original letter, CIGNA noted that in general, an in-network provider can not bill us for services not covered unless we agree to do so in writing (again nothing specifically signed here… although at admissions we signed the digital screen without getting an opportunity to review anything we signed). Has anyone had something like this happen before and how would you navigate? I’m worried I’ll get a bill for $12k but I think it’s the hospital’s issue to sort out with CIGNA. Edit- in Pennsylvania
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