An $80,000 surprise bill points to a loophole in a new law to protect patients

Article Summary: An insurer refused to pay bills related to the premature birth of
the Bull family’s twins because it said their delivery wasn’t an emergency and their
stays in the NICU weren’t medically necessary.

By Jay Hancock, NPR Shots, Feb 23, 2022.

When Greg and Sugar Bull were ready to start a family, health challenges
necessitated that they work with a gestational surrogate. The woman who carried
and gave birth to their twins lived two states away.

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

It was April 2020, early in the coronavirus pandemic. Unable to take 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 couple of weeks later, after the babies could eat and breathe on their own, the Bulls
took 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 gestational surrogate had her own
insurance, which covered her care.

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

Total bill: $117,084. The hospital was out of network for the infants. Cigna paid for
some of Scarlett’s care, for reasons the Bulls couldn’t figure out. The Bulls were left
on the hook for about $80,000, for both babies. Their account was ultimately sent to
collections.

Service provider: Utah Valley Hospital in Provo, Utah, one of 24 hospitals run by
Intermountain Healthcare, a nonprofit with about $8 billion in revenue.

What gives: The Bulls’ ordeal points up a loophole in coverage for emergency care
— even under the federal No Surprises Act, which went into effect on Jan. 1 and
outlaws many kinds of surprise medical bills.

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

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

That’s what happened to the Bulls. Cigna said it lacked documentation 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. They had expected to owe the family out-of-network, out-of-pocket maximum of $10,000 for the twins’ care. They assumed most of the bills would be paid by Cigna soon. They weren’t.

“I was like, there is no way this can 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 found the service requested 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, which
prompted Cigna to initially conclude there was no emergency, said Dylan Kirksey of
Resolve Medical Bills, a consultancy that eventually worked with the Bulls to resolve
the claims.

To establish that there was, Cigna asked for daily progress notes and other medical
records on the infants. The Bulls tried to get the hospital to comply. Cigna kept
saying it hadn’t received the necessary documentation.

The Bulls appealed. Sugar Bull spent hours with insurance paperwork and hold
music. But almost a year later, about $80,000 in bills remained. Utah Valley sent the
accounts to collections, she said. It was the last thing she had time for.

“I own a company, and I am super-busy and we had twins,” she said.”Every two
weeks or so, I would feel a panic and righteous anger about it. And I would keep
pushing and calling, and it would take, like, five hours every time.”

Though 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
attempt to keep their good credit.

Resolution: With seemingly nowhere else to turn, the family hired Resolve, which
beats a path through the claims jungle in return for a portion of the money it saves
clients.

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

In the end, most of the errors causing the Bull’s nightmare were on the hospital
side, Kirksey said. But instead of supplying what Cigna needed, Utah Valley went
after the Bulls.

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

“There were no errors on the hospital’s bills”, said Utah Valley spokesperson Daron
Cowley. “Utah Valley Hospital properly billed for services provided to the twins and
provided the requested information to Cigna in a timely manner.”

The hospital didn’t bill the Bulls for outstanding balances until nine months after the
twins were born and didn’t send the accounts to collections until six months after
that, after the family did not return the legally required paperwork to set up a
payment plan,” he said.

Finally, in the fall of 2021, the bills were settled. The twins were 1 1/2 years old. To
compensate Resolve for curing the balance, the Bulls paid the company about 10% —
$8,000.

The fee, though substantial and unrelated to medical care, was worth it to avoid the
much larger debt, said Greg Bull, who works in finance. “At the end of the day, it was
such a relief for it to be a smaller amount,” he said. Still, many families could not
have afforded it.

The takeaway: About 1 in 5 emergency room visits is at a facility that is out of
network for the patient’s insurance, research has shown. The No Surprises Act
requires insurers to cover non-network emergency treatment with the same patient cost-sharing as in-network care. It also prohibits hospitals from billing patients
extra.

But if the insurer denies that the care was for an emergency or doesn't obtain
documentation to prove that it was, the claim can still be rejected and the patient left
on the hook.

“That’s a coding issue we see a lot”, said Kirksey, “especially if the person didn’t
literally check-in through the emergency room.”

If this happens, insurance experts urge patients to immediately appeal the decision
to the insurance company, a process that the law requires be available.
Unfortunately, that usually requires more phone calls, paperwork and waiting. (If
the appeal with the insurer fails, patients can then turn to an independent reviewer,
like their state insurance board, state attorney general’s office or the No Surprises
Help Desk.)

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

Once it’s established that the visit was for an emergency, he said, protections from
the No Surprises Act clearly apply.

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

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