Retroactive pre-authorization denied for urgent care CT scan (medical, plan, doctor)

[cdajnj]

I am an NJ resident and have health insurance through my employer.

I went to an in-network urgent care (CityMD, part of Summit Health) with acute back pain, and the doctor at urgent care did an immediate CT Scan ("stat" CT Scan).

After the visit, they did a retroactive pre-authorization for the CT Scan to Aetna who have denied it. So Aetna wont cover the CT Scan or the radiology fee. The radiologist has tried to bill Aetna who have denied this already. CityMD hasn't tried billing Aetna for the CT Scan facility fee itself so far. But based on my experience with Summit Health, they will.

As per the rules of my plan, if I go to an in-network provider, the provider is responsible for getting pre-authorization for all procedures and they can't bill me for services provided if pre-authorization is denied.

However as part of registering at the urgent care facility, I had to sign an electronic legal agreement before they would see me. As part of this agreement, the patient is liable for paying all non-covered services. I have checked with Aetna and my HR and the blanket statement is that "patient is liable if there is a separate agreement signed with the provider"

So the question is - Can CityMD come after me with an inflated CT Scan bill even though insurance has denied this?

[jiminnm]

Did you sign a form indicating that you were responsible for the cost?

[skeddy]

sounds like you signed an agreement making you responsible. Try to lowery your cost to what Medicare pays for these services.

[Williepaws]

Originally Posted by skeddy

sounds like you signed an agreement making you responsible. Try to lowery your cost to what Medicare pays for these services.

how is the poster going to lower the cost to what medicare would pay?

[ged_782]

Originally Posted by skeddy

sounds like you signed an agreement making you responsible. Try to lowery your cost to what Medicare pays for these services.

Originally Posted by Williepaws

how is the poster going to lower the cost to what medicare would pay?

It doesn't sound to me like the OP has a Medicare plan. Only mentions that it is an employer plan.

Non-Medicare employer group insurance usually requires pre-authorization for certain services, similar to Medicare Advantage. But active employees generally are not going to have a Medicare plan available to them through their employer. A few (usually larger legacy-type employers) may offer a group Medicare plan to their eligible retirees.

[Lillie767]

If all provider claim requests are denied by the insurer, the OP can file an appeal. Many employer sponsored health and welfare plans are subject to federal laws, not state insurance laws.

The summary plan description provided to all participants should provide the claim appeal procedure.


If the appeals process fails, you can usually negotiate with the service provider to pay them what the insurance plan would have paid them. This is usually considerably less than the full billed amount.

[Vision67]

The Affordable Care Act (ACA) includes provisions that aim to protect consumers from certain insurance practices, including denying coverage for emergency services. Under the ACA, insurance companies are generally prohibited from denying coverage for emergency medical services, including emergency imaging procedures, based on factors such as pre-existing conditions or the lack of prior authorization. However, specific coverage details can vary depending on the individual insurance plan and state regulations. It's always a good idea to review your insurance policy or consult with your insurance provider to understand your coverage rights and limitations regarding emergency services.