Why won’t my post-op copay charges go away 😭
Hey fellow bisalp friends! Gonna try to keep this brief and hope the right people who can help find it, but as this has been going on for nearly a year now it might be a little lengthy, apologies. Tl;dr; if you’re well versed in fighting insurance for someone with a plan through their employer in California, I could really use your help!
Buckle up while I tell the tale of the persistent AF copay charges!
My surgery was 1/8/25. As I had gotten letters from my medical group (I have a Cigna HMO through my employer in California) that they had pre-approved me for CPT code 58661, being hit with a demand for a facility fee on the morning of my procedure came as quite an unpleasant surprise. I asked them to bill my insurance for this fee and was told that they already had. Admittedly, on the day of my surgery I didn’t know as much as I do now about what is supposed to be covered, and in fear of them cancelling my surgery I got set up on a payment plan for those facility fees.
Meanwhile, my pre-op on 1/2/25 was coded CPT 99214; I was not billed a copay for this appointment. The surgery went smoothly and my first post-op was 1/22/25. On this date, I don’t think my doctor fully understood just how much I have to pretzel myself while lifting heavy items in my job, so she sent me back to work without modifications the next day where I almost immediately popped an incision and needed a second post-op on 1/28/25. Both those visits were coded 99213, my doctors office expects those copays and this is where I am stuck in this fight.
Back in June 2025 (after several unsuccessful attempts in months prior), I finally landed on a Cigna rep who re-ran both the facility fees and the copays. I did get a full refund for the facility fees, but for some reason the appeal process for the copays couldn’t start until 7/1/25 and it could take up to 60 business days to get a decision, which would put that deadline at 9/25/25. Admittedly I took a pretty long vacation for most of the month of September and kind of forgot about the significance of 9/25 until I got a new bill from my doctors office for the price of those two copays. I spoke to a new Cigna rep on 10/14/25 who forwarded my file to the California HMO department (this is what was said, but after a google search I’m unsure exactly what department this is.)
This conversation came back in November with a letter that said I’m still responsible for the copays because they “were not related to the original surgery” (how did we ever come to that conclusion???). I filed an online grievance with Cigna in late November, and when I called in early January of 2026 to check the status, found out, conveniently, that the online one was never received and so did a new one over the phone. At this same time I also filed a complaint with the California department of insurance. Cigna came back with they reached out to my doctor to make sure the post-op visits were coded correctly, and she said they were. The DOI, however, said that because I have an employer-sponsored plan they cannot intervene and I would need to reach out to my HR department and see if I can get it ironed out that way (I don’t have a lot of faith in this method).
I was under the impression that the ACA mandate means that *everything* related to this procedure, including those two copays, should be at zero cost to me, right? Because why would I have to pay the post-op but not the pre-op? Also without the surgery I wouldn’t have needed those two post-op visits in the first place! Is there a different way the post-ops should have been coded? (If they ultimately wind up telling me I only get one and have to pay the other, fine, but I’m currently fighting both on principle.) Due to the current leadership in the U.S., finding this information has become convoluted, if anyone can point me in the right direction of that (or tell me what section in the 900ish pages of ACA to highlight), that would be rad!
I also saved last year’s schedule of copayments document through my employer that illustrates my case; in the box marked “Family Planning Services for Women” there are two sections, “Office Visits (Tests and Counseling)” and “Surgical Sterilization Procedures”, the column next to both states “no cost”. Is it worth fighting with HR or is there someone else I should be contacting?
Sorry this has been SO long, but if there’s anyone out there with remotely any insight on how I can plan for the next (and hopefully last, I’m so tired ugh) step of this fight, I appreciate you!!