If a pain clinic did not get prior authorization before doing a procedure on my husband and our insurer hasdenied the claim, are we still responsible?

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If a pain clinic did not get prior authorization before doing a procedure on my husband and our insurer hasdenied the claim, are we still responsible?

My husband had a nerve ablation done (it didn’t help) and he straight out asked them if they were going to get the prior authorization and they told him yes because he told them he did not want the procedure if the insurance was not going to pay. Well we got the EOB and the pain clinic did not get prior approval and now our insurer has denied the claim. I spoke with the insurance company and they told us not to pay it; it is not our responsibility. The pain clinic tried to get a retroactive authorization 6 months after the procedure and it was denied. Now they have sent us to collections. Can they do that since they are the ones that dropped the ball?

Asked on January 21, 2012 under Bankruptcy Law, West Virginia

Answers:

MD, Member, California Bar / FreeAdvice Contributing Attorney

Answered 9 years ago | Contributor

No, the pain clinic ran a scam and it didn't work. So now what you need to do is pull your credit reports from all three agencies because you get one free from each per year. See if it is on there. If it is, file a dispute of fraud and lack of medical authorization with the agencies so this can be taken off of your reports. If it is not on there, immediately contact the state medical board that licenses them and file a claim of fraud with the state attorney general and assault with the police. They touched your husband essentially without his permission since the condition of permission was based on insurance approval. In hindsight and for future purposes, you cannot rely on the statements by medical professionals or office staff to ensure you received insurance approval.


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