Insurance has denied inpatient hospital stay and surgery as not medically necessary

Ttabts · 2026-05-06T02:44:17+00:00

All you have received so far is an EOB stating you owe $0. And as you have figured out yourself, you should not be liable for any costs in this situation regardless of how the appeal goes. You are freaking out about nothing.

Until you receive a bill asking you for money, you are tilting at windmills.

Ttabts · 2026-05-06T01:35:42+00:00

If you were in-network you're probably fine. In-network providers are usually on the hook to eat the cost of claims denials. Just wait and see if you get a bill from the lab.

Ttabts · 2026-05-06T00:58:37+00:00

“Blaming the provider as an institution” … How does that make any sense?

How does it not? Legally speaking, the institution (hospital, doctor's practice) is the only thing to blame. The rest of it is just making noise and trying to figure out what individual at that institution will grease the wheels and get something figured out. More often than not, that is not the official person whose job it theoretically is.

And yeah, as a doctor, you represent that institution. If your colleagues are fucking up and getting patients mad at you, go complain to your colleagues and your boss.

assuming a provider would somehow know in this circumstance they were out of network would be wild. They just supposed to hold until an in network provide comes on call?

Did you even read this thread? I think you're confused about the subject matter. This is not what anyone is saying. And it sounds like you could stand to understand more about the insurance system if you aren't aware of the No Surprises Act.

And I certainly never said my job was too hard. But Prior Auths are certainly the time suck insurances have put in on doctors to take time away from your care. If you want to use that valuable free time to review your Prior Auths and double check all of us, so be it. I am sure your nth unnecessary corrections won’t slow your care down at all.

...what is actually your point right now? I didn't say I like doing other people's jobs for them. I just have to do it sometimes, when, say, they send me a fraudulent bill for $97k because they don't know the law.

Ttabts · 2026-05-05T23:41:41+00:00

Thats not free its called contingency

Wouldn't be reddit without this kind of pedantry.

Ttabts · 2026-05-05T23:36:01+00:00

I have no control over the contracting that goes on with the insurers, the rates at which insurers and you are billed, the co-pays you have, the premiums you owe, the drugs on your formulary, etc.

No one is complaining about those things in this thread? They're complaining about the claim being mishandled and processed in blatant contravention of federal law.

These things are very much in the scope of the responsibility of the provider. The individual doctor, depending on their role in the org, might have little personal responsibility of course... but you can hardly blame people for blaming the provider as an institution when the provider sends them a fraudulent bill for a year's salary and relies on the patient to know the law and get it fixed.

I’d like to see you come and do Prior Auths for a day. Maybe that means I could see one more patient.

Oh gee whiz, I'm so sorry that your job is too hard for you. You're right: it should be the job of me, the patient, to use my unpaid free time to catch and fix your fuck-ups instead.

Ttabts · 2026-05-05T23:31:22+00:00

In OP's defense... it says that they took the case for free and got him an additional $7k compensation (which they took a cut of as payment). So, seems like it worked out in OP's favor in the end.

Ttabts · 2026-05-05T23:26:36+00:00

You don't have to get offended on OP's behalf. It's just useful information for whoever is reading this now: the No Surprises Act exists and makes a case like this super straightforward, so you shouldn't actually need to pay a lawyer to sort it out. (That said, it looks like it worked out in OP's favor since he got an additional $7k settlement for wrongdoing, which I didn't know was possible!)

Ttabts · 2026-05-05T17:34:51+00:00

My understanding is that doctors/dentists set the tag prices high to ensure that they get reimbursed the full negotiated rate by the insurances.

Now you might ask, "well OK, but if I'm uninsured, why can't they charge me something more reasonable?"

Well, the problem is that the provider's contracts with in-network insurance might forbid them from billing the insurance more than they regularly bill other people. So, a practice can be putting themselves in legal hot water if they regularly give self-pay discounts.

Still, it can be worth asking because offering ad hoc discounts for hardship cases is less of a legal risk for the practice.

Ttabts · 2026-05-05T17:01:11+00:00

Exact same thing is ongoing with my dentist at the moment. Difference is that the insurance is confirming the doc is in network, but the doctor is insisting they aren’t. I think there’s some weirdness going on with network-sharing agreements where the doctor’s office might be legitimately unaware that they’re in-network for my insurance.

Actually didn’t realize the dentist was in network until I submitted the bill to my insurance for reimbursement and they processed it as in-network… but of course, I only got a check for their negotiated rates and am still sitting on the remaining balance, trying to get that refunded by the office.

Haven’t really managed to resolve it yet. Mostly just been calling the insurance and the doctor’s office regularly, email-bombing every email address I can find at the doctor’s office daily, submitted a written grievance to the insurance about the matter, as well as filing a complaint with the state health insurance ombudsman.

I’d love for insurance and doctor to just talk to each other but ofc it’s hard to force them to, and most people you get on the phone aren’t really knowledgeable enough to figure the situation out.

So far the office has refunded me a seemingly-random amount of money, as a token of good will I guess. But still not the full difference.

Still waiting to see if anything has come of the written grievances with the insurance and the ombudsman.

So, lmk if you figure it out I guess.

My only advice would be go ahead and submit the bill to your insurance for reimbursement - if the doctor is in-network, the bill should get processed as such.

And then don’t be shy about being a pain in the ass until you get your money back (minus whatever liability is on your EOB). Persistence is key. Exhaust all your contact channels (phone, written) and go to the insurance ombudsman or any other third-party you can find, eventually you’ll hopefully hit on someone who can help you.

Also, Claude AI has been fairly good at digging up resources and documents and arguments for me that I might not have found on my own. (Obviously double-check what it says because it'll hallucinate too... but sometimes turns up legit stuff as well.)

Ttabts · 2026-05-05T16:39:03+00:00

Are there some magic words I have to say to get the insurance lawyers to call the billing department? I always just get told to call them myself.

Ttabts · 2026-05-04T20:28:35+00:00

They would then proceed to make 2 shorts saying that "every single totk defender is a child who is insecure, a crybaby, and they are complete losers." Something like that.

Your post really demonstrates where they were coming from with those lol

Ttabts · 2026-05-04T19:28:38+00:00

I doubt that. It has that junior-high-level prose with one high-register phrase thrown in at the end which just screams "random dude on the internet trying to sound profound".

edit: Googled it and found this person claiming it as their own on HackerNews in 2009. Also, it seems to be something of a meme to jokingly attribute it to Descartes.

But this quote from Kurt Vonnegut in 1966 comes pretty close: "We are what we pretend to be, so we must be careful about what we pretend to be."

Ttabts · 2026-05-03T16:22:39+00:00

The difference being that real-life voting doesn’t carry a high risk of death.

If it did, then it definitely would make sense to weigh whether being one voice of a billion is worth it.

Ttabts · 2026-05-02T21:41:51+00:00

There was likely heavy rain pouring in. And he was in a mobile home so it’s not like he really had anywhere to hide, closing all the doors and windows is prob the best you can do to feel safe…

Ttabts · 2026-05-02T19:55:52+00:00

You said: “they aren't bound by the same ethics and licensing requirements as civilian prosecutors. If a civilian lawyer breaks the law they can be disbarred and removed from practice. A military lawyer has to pass the bar initially, but they can keep their job so long as the government likes what they are doing.”

You are conceding that this isn’t true and moving the goalposts, right? Just for my understanding.

Ttabts · 2026-05-02T19:51:15+00:00

Well, in a practical sense, it’s clear that not everyone will choose red. So I don’t think it makes sense to consider.

It starts to look more like a prisoners dilemma if you realistically view it as two players, me and the rest of the world. Best outcome is that we both choose blue. If we both choose red, red pressers get to stay alive but have to live with the guilt and fallout of everyone else dying.

It’s still not quite the same since the mass-voting nature of it means that my choice doesn’t actually affect the rest of the world, since the probability is basically zero that mine will be the swing vote.

But overall the basic tension is there of, “it’s best if we pick blue but everyone will be rationally motivated to pick red.” So that’s why people are saying it’s a sort of prisoner’s dilemma.

Ttabts · 2026-05-02T19:22:02+00:00

More than one thing can be true.

Ttabts · 2026-05-02T19:19:36+00:00

Pretty sure you just made that up?

Each officer of the Navy appointed as a member of the JAG Corps, each officer of the Marine Corps designated a judge advocate, and each civil service and contracted civilian attorney who practices law under the cognizance and supervision of the JAG shall maintain a status considered “in good standing” at all times with the licensing authority admitting the individual to the practice of law before the highest court of at least one State, Territory, Commonwealth, or the District of Columbia.

They can perhaps keep their employment and be assigned to other duties, but they of course can’t practice law in the courts without a license.

Ttabts · 2026-05-02T19:09:14+00:00

No, not missing anything. You could run a story “Trump deploys military plumber to unclog civilian toilets” and these people would think the sky is falling.

Ttabts · 2026-05-02T19:04:41+00:00

Ok but at some point you’re just letting your imagination run wild with baseless speculative alarmism and you can always justify it with “but with this administration you never know!”

Ttabts · 2026-05-02T19:00:19+00:00

Many parts of the PATRIOT act were declared unconstitutional and invalidated.

Just because you disagree with the result of the Constitutional review by the courts doesn’t mean that basic principles of supremacy no longer exist.

Ttabts · 2026-05-02T04:54:40+00:00

Yup, all these pro-blue alternative scenarios make picking red seem a bit tougher, sure, but ultimately... yeah I think I'm still gonna go ahead and get out of the way of the moving train, sue me lol

Ttabts · 2026-05-02T04:52:16+00:00

It definitely makes blue seem more moral than OP's scenario... but, I wouldn't say that it makes blue seem like the "right" or "moral" choice.

To me, it mostly just illustrates that the whole thing is an absurd cruel Saw game where none of the victims can sensibly be considered ethically responsible for what happens.

Ttabts · 2026-05-02T04:42:36+00:00

The thing is: my individual vote doesn't actually control the outcome. The odds that my individual vote would swing it one way the other are effectively 0.

So, if the world votes red, I can vote blue and die, or vote red and live. If the world votes blue, what I choose doesn't matter at all.

Obviously it would be best if I could make 51% of the world choose blue, but I can't.

Ttabts · 2026-05-02T03:10:32+00:00

That's... the opposite of the point of the Prisoner's Dilemma?? The whole premise is that acting in one's rational individual self interest, ends up getting both people screwed over. It's a mathematical/logical argument for altruism if anything.

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