Clinic Failed to Get Prior Authorization, Insurer Says We Owe Nothing—Clinic Still Billing Us

My wife had a procedure at a specialty clinic that’s part of our local hospital system, which is in-network with our insurance. We specifically chose this insurance plan because it covers the procedure. Our insurer has been great, but the clinic has been a nightmare.

Apparently, the clinic never submitted prior authorization, so our insurer denied the claim. The Explanation of Benefits (EOB) clearly states that the denial is due to missing prior authorization—not because the procedure isn’t covered. It also states that because of this, we don’t owe anything. However, the clinic sent us a bill saying the procedure was denied because:

It isn’t covered by our policy.

There’s an exclusion in our policy for it.

It has nothing to do with prior authorization.

This directly contradicts what our insurer is saying. We checked with them, and they confirmed:

✔ The procedure is covered under our policy.

✔ There is no exclusion for it.

✔ The clinic should have submitted prior authorization.

Our insurer even sent us copies of our policy proving this and repeatedly told us that we shouldn’t owe anything because the clinic dropped the ball. They’ve also suggested the clinic could submit a retroactive prior authorization request to fix the issue.

However the clinic refuses to engage in a meaningful conversation. The hospital system is huge and bureaucratic, and customer service just refers us back to the clinic. The clinic’s “financial counselor” won’t speak with us over the phone—only through the hospital’s portal messaging system. She keeps repeating things that directly contradict our policy and what our insurer says, like:

The procedure isn’t covered.

There’s an exclusion for it.

The insurer considers it “testing,” which never requires prior authorization.

Insurers sometimes deny for prior authorization when that’s not the “real reason.”

When we point out the discrepancies, she ignores or brushes them off. She takes days to respond and is completely unhelpful.

The insurance company seems to be on our side, and the CPT code looks correct, so it doesn’t make sense to appeal the denial. But we can’t force the clinic to fix their mistake or submit a retroactive prior authorization request.

There’s no one else at the clinic who deals with billing and insurance, and the hospital system keeps sending us back to them.

We’re at a loss—what can we do?