For the most part, Keyanna Jones and her husband thought they knew what to expect when their daughter Chlo毛 had eye surgery last fall.
Even Chlo毛, who was in kindergarten, had a good understanding of how things would go that day. Before the procedure, a hospital worker gave her a coloring book that explained the steps of the surgery 鈥� a procedure to correct a condition that could have eventually interfered with her vision.
鈥淐hlo毛 is very smart,鈥� Jones said. 鈥淪he reads at almost a third-grade level now, and she鈥檚 only 6.鈥�
Jones did her homework, too. With no pediatric ophthalmologists near their home in Wentzville, Missouri, who would take their insurance, she asked the insurer to cover Chlo毛鈥檚 out-of-network care as if it were in-network. The insurer agreed to let her see an out-of-network specialist.
Chlo毛 made it through surgery without a hitch. Jones said her daughter enjoyed a few popsicles at the hospital before going home.
鈥溾�奍 slept with her every night because she was so worried she would wake up and not be able to see,鈥� she said. 鈥淏ut it healed beautifully, and she was absolutely ready to go back to school.鈥�
Then the bill came.聽
The Medical Procedure
Chlo毛 was born with a droopy left eyelid, a condition known as ptosis. To correct the problem, an ophthalmologist surgically lifts the eyelid, preventing it from disrupting the patient鈥檚 line of sight.
Ophthalmologists, unlike optometrists and opticians, hold medical degrees and can provide advanced eye care, including surgery.
The Final Bill
$15,188, including $10,382 for the procedure and $2,730 for anesthesia. Initially, insurance paid just $1,775.79, leaving the Jones family owing $13,412.21 鈥� until Chlo毛鈥檚 uncle, who had recently finished his term as a state senator, asked a colleague to look into it.
The Problem: Phantom Insurance Approval?
Months before Chlo毛 inhaled bubblegum-scented anesthetic at Cardinal Glennon Children鈥檚 Hospital in St. Louis, Jones discovered that it can be hard to find a pediatric ophthalmologist. The doctor recommended by Chlo毛鈥檚 pediatrician wasn鈥檛 contracted with their insurer, UnitedHealthcare, and the closest in-network specialist was in Wisconsin, hundreds of miles away.
So Jones requested what鈥檚 called a network gap exception, under which the insurer would cover the recommended doctor鈥檚 services as in-network.
Before the surgery was scheduled, she received a letter saying UnitedHealthcare had approved her request 鈥渂ecause currently there isn鈥檛 a doctor, health care professional, or facility in your area to provide these services.鈥� The letter listed several medical billing codes for eye services and said they would be covered 鈥渁t the network level.鈥�
About a week later, the insurer sent a prior authorization letter approving Chlo毛鈥檚 surgery.
But UnitedHealthcare declined to pay most of the surgery bill, covering it as out-of-network. With approval letters in hand, Jones said, she did not understand why the insurer apparently was not honoring its agreement to cover her daughter鈥檚 treatment.
In fact, the similar-looking letters granted different kinds of approval.
UnitedHealthcare鈥檚 gap exception approved Chlo毛鈥檚 exams before the surgery as in-network. But in its prior authorization letter for her surgery with the same doctor, the insurer said only that it would cover it 鈥� without offering network discounts.
After receiving the bill, Jones contacted the insurer online, but she said a representative told her there was no record of its approval to cover the surgery as in-network.
鈥淎t that point, I didn鈥檛 even know what to do,鈥� she said. 鈥淚鈥檓 like, 鈥楾his is crazy.鈥欌��
She said she sent over a copy of one of the approval letters, which was on the company鈥檚 letterhead, but a representative told her the letter hadn鈥檛 come from UnitedHealthcare.
鈥淭hey said, 鈥榊ou saw this surgeon, they鈥檙e not covered and you didn鈥檛 have permission, so, no, we鈥檙e not going to pay,鈥欌�� Jones said, recounting the phone call.
An insurance representative told Jones she owed more than $13,000 because of 鈥渁 balance billing issue.鈥� That meant the Jones family would have to pay the $13,000-plus balance.
Spokespeople for UnitedHealthcare confirmed the company provided a gap exception and prior authorization for Chlo毛鈥檚 care. Eric Hausman, a spokesperson for UnitedHealth Group, said in a statement to 黑料吃瓜网 News that 鈥渨e empathize with anyone who finds themselves in the unfortunate situation of being balance billed by an out-of-network provider for an amount significantly above market rates, and without any advance knowledge.鈥�
Maryanne Wallace, a spokesperson for SSM Health, the health system that includes Cardinal Glennon Children鈥檚 Hospital, provided a statement that said SSM followed 鈥渟tandard patient billing procedures.鈥�
鈥淥ccasionally, an insurance company may process a claim as an out-of-network service, which can result in a balance being billed to the patient,鈥� the statement said.
The Resolution
Jones said she was blindsided by the big bill. She tried to fix the problem on her own, she said, keeping track of every interaction with the insurer and the hospital. She filed appeals with UnitedHealthcare.
Nothing helped 鈥� until she reached out to her brother Caleb Rowden, who had been a Missouri state senator for eight years after serving four years in the state House.
鈥溾�奍鈥檝e never used my brother鈥檚 political clout for anything,鈥� she said. 鈥淚 actually hate politics.鈥�
Rowden told 黑料吃瓜网 News that he reached out to Travis Fitzwater, the state senator representing his niece鈥檚 district. Jones contacted Fitzwater鈥檚 office, too, and sent a complaint to Missouri Attorney General Andrew Bailey.
Fitzwater said his office did no more for Chlo毛 than it would for any constituent.
鈥淲e鈥檙e not going to take a lot of credit for the result of it, because we didn鈥檛 ask for anything other than a resolution, so that everybody can be at peace and move on with their lives,鈥� he said in an interview. 鈥淲e just did what we do every day.鈥�
After Fitzwater鈥檚 staff contacted the hospital and the insurer, representatives from both separately called Jones and notified her that UnitedHealthcare had paid the bill in full.
In the end, Chlo毛鈥檚 family paid nothing for her procedure 鈥� not even a copay.
The Takeaway
When it comes to insurance approvals, read the fine print carefully; 鈥渃overed鈥� does not mean an insurer will pay, let alone at in-network rates.
Rowden and Fitzwater said reaching out to your elected representative鈥檚 office can help. Advocating for constituents is part of their job.
鈥淭hey usually have an open line of communication with these insurance companies and hospitals,鈥� Rowden wrote in an email. 鈥淭hey may not always be able to get to a positive outcome since every situation is a little different, but they can usually get you to a next step.鈥�
Jones is grateful that her brother was able to help, though she acknowledged that she probably would not have called him without a nudge from their mother. 鈥淚 think I would still be fighting,鈥� she said.
Bill of the Month is a crowdsourced investigation by 黑料吃瓜网 News and that dissects and explains medical bills.聽Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!