All very valid points and part of why American health insurance is such a joke
I had an incident recently where my spouse had to go to the ER because of a life threatening incident. One of those fix it right now or they might die things. (They’re fine now, thank goodness.)
We went to an in-network hospital and all doctors were also in-network. However the one who actually did the life-saving procedure was a specialist. Under our insurance plan seeing a specialist requires a referral, which of course we didn’t have time to get. So insurance tried to nope out of that doctor’s entire bill.
I don’t know the actual answer. My theory is it’s this confusing so it’s hard for the general population to catch the mistakes. This allows insurance companies get out of paying as much as they’re supposed to. And hospitals don’t really care who does the paying, as long as they get paid