Out of Network Benefits & Repeated Claim Denials
Hi all! New here. At my wits’ end with my insurer.
I have out of network benefits on my PPO plan. My insurer pays (according to plan agreement) 70% of out of network costs if I see an out of network provider.
I see someone every week who is out of network. I’ve had this plan for four years with minimal issue seeing this provider and being reimbursed 70% for visits (including the first few months of this year). May of this year, insurer stops reimbursing. Not officially, but just denials. Over and over again. Different reasons each time. For example, providers address can’t be verified, not covered services, etc…
It’s unbelievably frustrating. I reviewed the plan details from this year vs previous years—absolutely no difference. Also reviewed the stationary/letterhead of the provider whose address supposedly couldn’t be verified. No difference between letterhead on what was attached to approved claims vs. denied. I even talked to a rep on the phone who said something along the lines of “oh yea, the provider’s address is fine, we’ll verify, update it in our system and resubmit that claim for you.” Claim got denied again a week later. After that the denials continued, just for new reasons.
I’m beginning to think that they have no plans to reimburse me and are hoping I just give up. They owe me a few thousand in reimbursements at this point, per the details of my plan.
Anyone ever experienced anything similar? Leaving insurance company’s name off as I’m unsure of the particulars for this on this sub, but I’m in NY (NYC specifically).
TL;DR: Insurance company stopped reimbursements for out of network services in the middle of plan year.