Bill of the month: $80,000 tab for newborns presents loophole in new law to reduce surprise bills

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When Greg and Sugar Bull were ready to start a family, health issues required them to work with a surrogate. The woman who carried and gave birth to their twins lived two states away.

The pregnancy went well until the surrogate suffered from high blood pressure and other symptoms of preeclampsia, which could have harmed her and the babies. Doctors ordered an emergency delivery at 34 weeks gestation. Both infants had to spend more than a week in the neonatal intensive care unit.

It was in April 2020, at the start of the pandemic. Unable to catch a plane, the Bulls drove from their home in Huntington Beach, Calif., to the hospital in Provo, Utah. They had to quarantine in Utah before they could see the children in the hospital.

A few weeks later, after the babies were able to eat and breathe on their own, the Bulls flew them home to California.

Then the bills came.

The patients: Scarlett and Redford Bull, newborn twins covered by a Cigna policy sponsored by Greg Bull’s employer. The surrogate mother had her own insurance, which covered her care.

Medical service: Neonatal intensive care when babies are born prematurely after emergency induced labour. Scarlett spent 16 days in the NICU; Redford, 10.

Total bill: $117,084. The hospital was off the grid for infants. Cigna paid for part of Scarlett’s care, for reasons the Bulls couldn’t understand. The Bulls were left on the hook for around $80,000, for the two babies. Their account was eventually sent to collections.

Service provider: Utah Valley Hospital in Provo, Utah, one of 24 hospitals operated by Intermountain Healthcare, a nonprofit organization with approximately $8 billion In income.

Which give: The Bulls’ ordeal highlights a loophole in emergency care coverage — even under the No Surprises Act, which took effect Jan. 1 and bans many types of surprise medical bills.

Patients who need quick and life-saving treatment often don’t have time to find a network hospital. In the past, health plans have sometimes said they’ll pay for emergency care even if it’s out of network. The No Surprises Act now makes it a legal requirement in every state. The provider and the insurer are supposed to negotiate a reasonable payment, leaving the patient out of the equation.

But what if the insurance company denies that the care is for an emergency? Or the hospital won’t provide the paperwork to prove it?

That’s what happened to the Bulls. Cigna said there was a lack of documentation indicating that the NICU care for the twins qualified as an emergency.

So the Bulls began receiving insurance explanations showing huge balances owed to Utah Valley. The family expected to owe their maximum out of the network and shell out $10,000 for the twins’ care. They assumed most of the bills would soon be paid by Cigna. They weren’t.

“I was, like, there’s no way this could be real,” said Sugar Bull, an interior designer.

“Dear Scarlett Bull,” began one of Cigna’s letters, addressed to a 6-month-old baby. “We have found that the requested service is not medically necessary.”

How could NICU care not qualify? The gestational surrogate was admitted to obstetrics by her doctor without going through the emergency department, prompting Cigna to initially conclude there was no emergency, said Dylan Kirksey of Resolve Medical Bills, a consulting firm that eventually worked with the Bulls to resolve the claims.

To establish that there had been, Cigna requested daily progress notes and other medical records on the infants. The Bulls tried to force the hospital to comply. Cigna kept saying she hadn’t received the necessary documentation.

The Bulls appealed. Sugar spent hours with insurance papers and music on hold. But nearly a year later, there were still around $80,000 worth of bills. Utah Valley sent the accounts to collections, Sugar Bull said. It was the last thing she had time for.

“I own a business, and I’m very busy, and we had twins,” she said. “Every two weeks or so I felt panic and righteous anger about it. And I kept pushing and calling, and it took about five hours each time.

Although they disputed what they were being charged, the Bulls agreed to pay the hospital $500 a month for five years to settle just one of the babies’ bills, in an effort to maintain their good credit.

Resolution: Seemingly having nowhere to go, the family hired Resolve, which weaves its way through the claims jungle in exchange for some of the money it saves customers.

“It took a lot of prodding” to get Utah Valley to give Cigna the information it needed to pay the hospital, said Kirksey, a senior attorney at Resolve, which was founded in 2019 and has 16 employees. He said he had to give the hospital a detailed list of what to do and then follow up with several calls and emails a week.

Ultimately, most of the mistakes that caused the Bulls’ nightmare were on the hospital side, Kirksey said. But instead of providing what Cigna needed, Utah Valley went after the Bulls.

“The hospital has repeatedly failed to provide a detailed list of services and important clinical information, despite our continued efforts to secure the information,” Cigna spokeswoman Meaghan MacDonald said.

“There was no error on the part of the hospital,” Utah Valley spokesman Daron Cowley said. “Utah Valley Hospital correctly billed for the services provided to the twins and provided the requested information to Cigna in a timely manner.”

The hospital didn’t bill the Bulls for the outstanding balances until nine months after the twins were born and didn’t send the accounts to collections until six months later, “after the family failed to return legally required documents. to establish a payment schedule,” he said.

Finally, in the fall of 2021, the bills were paid. The twins were 1.5 years old. To compensate Resolve for settling the balance, the Bulls paid the company approximately 10% – $8,000.

The costs, while substantial and unrelated to medical care, were worth it to avoid much larger debt, said Greg Bull, who works in finance. “At the end of the day, it was such a relief that it was a lesser amount,” he said. Yet many families could not have afforded it.

The takeaway: About 1 in 5 ER visits are to out-of-network facilities for patient insurance, studies have shown. The law without surprise requires insurers to cover out-of-network emergency care with the same co-payment of the patient as in-network care. It also prohibits hospitals from charging additional fees to patients.

But if the insurer denies the care was for an emergency or doesn’t get documentation to prove it, the claim can still be denied and the patient left behind.

“It’s a coding issue that we see often,” Kirksey said, particularly “if the person hasn’t literally checked into the ER.”

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If this happens, insurance experts are urging patients to immediately appeal the decision to the insurance company, a process the law requires to be available. Unfortunately, this usually requires more phone calls, paperwork, and waiting. (If the appeal to the insurer fails, then patients can go to an independent reviewer, such as their state insurance commission, state attorney general’s office, or Assistance service without surprises.)

“This would be a critical step for the consumer to leverage their appeal rights…and get it determined to be an emergency service from the start,” said Kevin Lucia, co-director of the Georgetown University Center on Health Insurance Reforms. .

Once it is established that the visit was for an emergency, he said, the unsurprisingly legal protections clearly apply.

The No Surprises Act is a step in the right direction. But it is clear that loopholes and minefields remain.

Stephanie O’Neill contributed to the audio portrait with this story.

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