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I was diagnosed with breast cancer in Sept 2015. Tricare…

I was diagnosed with...

I was diagnosed with breast cancer in Sept 2015. Tricare preapproved mastectomies and paid for the surgery. Now, in Feb 2016, a medical review board has denied the claim, and has recouped the payments sent to the hospital and providers. They say the specific technique used was not covered. I was never told that a "skin/nipple-sparing" surgery was not covered. The reclaimed payment is quite high, and now I'm afraid the providers will come after me for payment. Most of the providers were network, so they are supposed to "eat" the loss, but some are not and can charge me the full amount. I had no idea this could happen after they surgery was approved. Can you help me?

Lawyer's Assistant: Thanks. Can you give me any more details about your issue?

My cancer was caught early, and was not invasive. However, I have 2 sisters with breast and ovarian cancer, so I am high risk. I tested pos for the breast cancer gene, so my doctors advised bilateral mastectomies as the best treatment. They did a "nipple-sparing" surgery. Apparently, this type of technique is not covered by Tricare. No one ever told me that before surgery. And the hospital is the one who got approval for it. thanks, Ellen

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2/9/2016
Phillips Esq.
Phillips Esq., Attorney-at-Law
Category: Military Law
Satisfied Customers: 22,757
Experience: B.A.; M.B.A.; J.D.
Verified

You are not responsible for this bill.

The hospital has to "eat the loss" because it was the one that got the approval. Had it been that you did not get the approval for the surgery, you probably would have opted for an alternate procedure that would be covered by your insurance. So, your defense here against being held liable for this huge bill would be detrimental reliance. You did a sugery that you would not have done and incurred expenses that you would not have incurred but for the hospital getting approval from your insurance company that the surgery would be covered.

Phillips Esq.
Phillips Esq., Attorney-at-Law
Category: Military Law
Satisfied Customers: 22,757
Experience: B.A.; M.B.A.; J.D.
Verified
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