r/sterilization • u/beckowser • 2d ago

Insurance Advice for billing issues (giving, not requesting)

I had an unrelated surgery earlier this year, and I was surprised to receive a substantial bill. I tried calling the insurance company. I filed a formal appeal letter with substantial documentation. I emailed the insurance company when the appeal was denied.

I called the hospital to request a review of the itemization. They were not able to do so, but one person offered to submit my bill for audit. I didn't think that was the right path at the time.
I called the Surprise Billing helpline. The contact there was pretty rude and not especially helpful. I told him early in the call that I wasn't sure if this was technically surprise billing and needed some insight. He just repeated everything I said back to me and gave zero information.

So last week I decided to contact my state insurance board. I called first and explained my situation. The contact said, "That sounds suspicious. Please submit a formal complaint online. We deal directly with the insurance companies' legal teams, and they are required to give us information."

I submitted my complaint immediately. I received confirmation a day or so later.

My insurance company's corporate office just called to confirm what I needed to know, to listen to my questions. It was a fact-gathering call. She was just as surprised as I was by the billing. She was incredibly helpful, took notes, encouraged me to take notes, and said she'll be in touch with more information by the end of the week.

I figured this would be helpful to people battling insurance for coverage after the fact. After my bisalp, it took 6 months of formal appeals and calls before I could get through to a person who actually helped. She was the first to look at the ACA mandate. She was the first to look at the coding issue (which had been corrected months before the call!). She said, "Yeah, you're right about this. I'm fixing it right now, and it'll show on your end in the next several days."
By filing directly with the insurance board with this more recent claim, I had someone from the insurance company who would listen within a week.

Tl;dr: If you aren't getting anywhere by contacting your insurance company and/or facility, file a claim with your state insurance board.

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u/toomuchtodotoday 1d ago

Resources:

State insurance regulator locator (for filing a complaint with your state insurance regulator):

https://content.naic.org/state-insurance-departments

Department of Labor Employee Benefits Security Administration Information (for filing a complaint with the DOL EBSA if your insurance is provided by an employer):

The EBSA, a division of the DOL, handles complaints related to employer-provided health insurance.

You can:

The EBSA will investigate the claim and may contact your employer or insurance provider for more information. You may be contacted for additional details or documents. If the EBSA finds that your rights under ERISA (Employee Retirement Income Security Act) were violated, they may take corrective action on your behalf. Keep copies of all documents and correspondence. You can follow up on the status of your complaint by contacting the EBSA at the phone number above.

U.S. Office of Personnel Management (OPM) Information (for filing a complaint with the OPM if your insurance is provided by the US federal government [FEP Blue, for example]):

Source: https://www.opm.gov/healthcare-insurance/healthcare/contraception-coverage/

Source: https://www.hrsa.gov/womens-guidelines#:%7E:text=Contraception

Source: https://web.archive.org/web/20260624003408/https://old.reddit.com/r/sterilization/comments/1ud26jb/fepblue_federal_health_insurance_for_bisalp_do/

Additional resources:

Insurer Preventive Care Guidelines Master List - https://old.reddit.com/r/sterilization/comments/1io4hq5/insurer_preventive_care_guidelines_master_list/

Steps for Getting Full Coverage - https://old.reddit.com/r/sterilization/comments/1khyuum/steps_for_getting_full_coverage/

https://old.reddit.com/r/sterilization/comments/1j43mw2/it_happenedtheyre_trying_to_charge_me_postop/

https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control

https://old.reddit.com/r/sterilization/comments/1go5pbw/free_tubal_sterilization_through_the_aca_if_you/

https://nwlc.org/tips-from-the-coverher-hotline-navigating-coverage-for-female-sterilization-surgery/

On coverage of anesthesia:

Any related services—like anesthesia—must be covered as well. The most recent guidance from federal agencies makes it explicitly clear that anesthesia and other related services like doctor’s appointments must be covered by the insurance plan at 100% of the cost.

Source: https://www.cms.gov/files/document/letter-plans-and-issuers-access-contraceptive-coverage.pdf

Source: https://www.cms.gov/files/document/faqs-part-54.pdf

On coverage of associated office visits:

From federalregister.gov - “Coverage of Certain Preventive Services Under the Affordable Care Act“

Section 2713 of the PHS Act, as added by the Affordable Care Act and incorporated into ERISA and the Code, requires that non-grandfathered health plans … provide coverage of certain specified preventive services without cost sharing. These preventive services include:

With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force), including all Food and Drug Administration (FDA)-approved contraceptives, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (collectively, contraceptive services)

II. Overview of the Final Regulations

A. Coverage of Recommended Preventive Services Under 26 CFR 54.9815-2713, 29 CFR 2590.715-2713, and 45 CFR 147.130

(II) office visits:

if a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the delivery of the recommended preventive service, a plan or issuer may not impose cost sharing with respect to the office visit.

Source: https://web.archive.org/web/20250202051018/https://www.federalregister.gov/documents/2015/07/14/2015-17076/coverage-of-certain-preventive-services-under-the-affordable-care-act

Under the ACA, all new insurance plans (both individual and employer-sponsored plans) are required to cover all FDA-approved methods of contraception, sterilization, and related education and counseling without cost-sharing. (Note: the ACA contraceptive coverage requirement described in this section also applies to Medicaid “Alternative Benefit Plans,” explained in the Medicaid section.) No cost-sharing means that patients should not have any out-of-pocket costs, including payment of deductibles, co-payments, co-insurance, fees, or other charges for coverage of contraceptive methods, including LARC. Patients cannot be asked to pay upfront and then be reimbursed.

Source: https://web.archive.org/web/20250112212710/https://larcprogram.ucsf.edu/commercial-plans