Caitlyn Mai underwent cochlear implant surgical procedure together with her insurer’s approval, anticipating it could be lined in full. Then she began getting payments for $139,000.
Nick Oxford/KFF Well being Information
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Nick Oxford/KFF Well being Information
Caitlyn Mai awakened one morning in center college so dizzy she could not stand and in addition deaf in a single ear, the results of an an infection that affected one in every of her cranial nerves. Although her steadiness recovered, the listening to by no means got here again.
Rising up, she realized to manage — however it wasn’t straightforward. With just one functioning ear, she could not inform the place sounds have been coming from. She could not comply with together with teams of individuals in dialog — at social gatherings or at work — so she realized to lip-read.
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and NPR that dissects and explains medical payments. Do you have got an attention-grabbing medical invoice you wish to share with us? Inform us about it!
For a few years, insurers would not approve cochlear implants for single-sided deafness as a consequence of considerations that it could be onerous to coach the mind to handle alerts from a organic ear and one which hears with assistance from an implant. However analysis on the detrimental results of single-sided deafness and enhancements in method modified all that.
So Mai, now 27 and residing close to Oklahoma Metropolis, was thrilled final fall to get a previous authorization letter from her insurer saying she was lined for cochlear implant surgical procedure.
She had profitable outpatient surgical procedure to implant the gadget in December and shortly after was eagerly attending remedy to get her mind accustomed to its new capabilities.
“It was superb. After I’d misplaced my telephone and it rang, I may inform the place the sound was coming from and discover it,” she mentioned.
Then the invoice got here.
The affected person: Caitlyn Mai, who’s insured by way of her husband’s job by HealthSmart, which is owned by UnitedHealth Group.
Medical providers: cochlear implant surgical procedure, together with the working room, anesthesia, surgical provides and medicines.
Service supplier: SSM Well being Bone & Joint Hospital at St. Anthony, an orthopedic hospital in Oklahoma Metropolis that’s a part of SSM Well being, a Catholic well being system within the central U.S.
Complete invoice: $139,362.74 — or, with a “immediate pay low cost” if she paid about two months after surgical procedure, $125,426.47.
What provides: Suppliers and insurers usually have disagreements over how a invoice is submitted or coded, and as they work by way of them (or do not), the affected person is left holding the bag, going through generally big payments.
“I virtually had a coronary heart assault once I opened the invoice,” Mai mentioned of the primary month-to-month missive, which arrived in late December. She mentioned she was so upset she left work to analyze. Earlier than surgical procedure, “I would even checked that each one hospitals and medical doctors have been in community and that I would met my deductible,” she mentioned.
Whereas she was by no means threatened with having her invoice despatched to collections, she mentioned she nervous about that risk when the identical payments arrived in January, February and March with ominous warnings that “your steadiness is now overdue.”
Mai mentioned that she first known as the hospital’s billing workplace however that the consultant may inform her solely that the declare had been denied and the consultant did not know why. Mai known as her insurer, and a consultant there mentioned the hospital did not adequately itemize its prices or embody billing codes. She then known as again the hospital and relayed precisely what her insurer mentioned have to be achieved to rectify the invoice, in addition to the identify and variety of the insurance coverage worker to fax it to.
When her insurer advised her per week or two later that it hadn’t acquired a corrected invoice, Mai mentioned, she known as the hospital once more — and once more.
“I mentioned, ‘I’ve achieved your job for you — now are you able to please take it from right here?'” she mentioned.
Mai mentioned a hospital staffer promised to fax over the corrected, itemized invoice in two to 3 weeks. “How does it take that lengthy to ship a fax?” she puzzled. She mentioned she requested to talk with a supervisor and was advised the individual wasn’t out there however would name her again. Nobody did.
After receiving one other $139,000 invoice in late February, Mai mentioned, she checked again in together with her insurer, however a consultant mentioned it had not but acquired the revised invoice.
Lastly, she mentioned, she advised the hospital to “simply ship it to me and I will ship it over.” This time, she forwarded the invoice to her insurer herself. However in late March, she received one other invoice demanding the complete quantity — and providing an $11,000-a-month fee plan.
Mai mentioned she had met her out-of-pocket deductible and, with prior authorization in hand, anticipated the surgical procedure to be absolutely lined. 
SSM Well being didn’t reply to a number of requests for remark about why it billed Mai.
“It is outrageous that the sufferers find yourself umpiring the choices,” mentioned Elisabeth Ryden Benjamin, vice chairman of well being initiatives on the Group Service Society of New York, an advocacy group. “And it is outrageous that suppliers are allowed to invoice sufferers whereas they’re haggling with the insurer.”
Certainly, increasingly more sufferers are caught with such payments as insurers and hospitals spend increasingly more time arguing within the trenches, information reveals. A current report by Crowe, an accounting agency that works with numerous hospitals, discovered that greater than 30% of claims submitted to business insurers early final 12 months weren’t paid for greater than 90 days, which is hanging in comparison with the decrease charges of such delays with Medicare — 12% for inpatient claims and 11% for outpatient claims.
The Crowe report discovered {that a} explicit justification for denying claims was cited at 12 occasions the speed by business insurers as by Medicare: that they wanted extra info earlier than they’d course of the submission. Such a request permits insurers to sidestep legal guidelines in most states that require that claims be paid in 30 to 40 days, robotically granting well being plans the best to delay fee.
In a separate evaluation, the American Hospital Affiliation complained that will increase in insurance coverage denials and delays “pressure hospital assets” and “inhibit medically obligatory care.”
However maybe nobody is harmed as gravely because the affected person, who’s barraged with payments and believes they have to pay up — significantly when the missives are stamped “overdue” and include affords of prompt-payment reductions or no-interest fee plans. “The stress and anxiousness was big,” Mai mentioned.
Caroline Landree, a spokesperson for UnitedHealth Group, mentioned the insurer may pay Mai’s claims solely “after receiving an in depth invoice from her supplier.”
“We encourage our members to contact the quantity on their insurance coverage playing cards for extra info on the standing of funds,” she added.
The decision: Mai estimated she spent not less than 12 hours on the telephone doing duties that usually fall to somebody working in a hospital’s billing division — ensuring that the invoice was coded as wanted and that the insurer had what it needed to course of the fee.
Greater than 90 days after her surgical procedure, after Mai had acquired 4 terrifyingly big payments, her insurance coverage lastly paid the declare. Mai owed nothing extra.
She added: “I’ve by no means received that decision again from a supervisor to at the present time.”
The takeaway: It isn’t unusual for an insurer to delay paying a declare till it receives an itemized invoice. Suppliers generally get inventive with billing codes to extend income, and research present that greater than half of hospital payments include errors. However research additionally counsel that insurers are wont to tug their ft, niggling over coding and prices — and, in doing so, delaying reimbursement and holding onto the money.
Medical billing specialists say it could not appear proper for sufferers to obtain payments as this course of performs out however that it is most likely authorized.
“Legal guidelines say, maintain the affected person innocent,” Benjamin mentioned. “What we did not say is, do not ship them a invoice.” She mentioned it is usually unfair that sufferers could also be compelled to behave because the go-between for suppliers and insurers that ought to be speaking to one another.
What’s a affected person to do? First step: Do not pay the invoice (other than a copay or coinsurance) for care or providers preapproved by insurance coverage. Name the well being care supplier and clarify that it ought to take up its invoice with the insurer.
Second, ask the supplier to ship an itemized invoice with all billing codes used; then evaluation it for errors. Because the affected person, you’d know that you simply by no means had an MRI, for instance. Your insurer would not.
If submissions to Invoice of the Month are reflective of developments, many sufferers lately are discovering themselves pingponging between representatives for suppliers and insurers to get payments resolved and paid.
“Bravo for Ms. Mai for having the power to maintain at it and get decision,” Benjamin mentioned.
KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF — an unbiased supply for well being coverage analysis, polling and journalism.
Emmarie Huetteman of KFF Well being Information edited the digital story. Taunya English and Simone Popperl of KFF Well being Information, together with NPR’s Will Stone, edited the audio story.
