Denver Doctor Hit by Car Faces $63K Bill After Insurance Denial — Why No Surprises Act Failed Her

A Doctor's Unexpected Medical Bill

In February, Dr. Lauren Hughes, a physician in Denver, found herself in an unexpected situation when she was involved in a car accident that left her with a broken ankle and a deep knee cut. She was taken to the Platte Valley Medical Center, where she underwent surgery. However, what followed was a surprise — a hospital bill of $63,976.35.

Hughes, who is also the director of the Farley Health Policy Center at the University of Colorado, was shocked by the amount. She had assumed that her insurance would cover the costs, but it turned out that the hospital was out of network, and her insurance didn't cover inpatient treatment. Additionally, she didn't qualify for protection under the No Surprises Act, which is designed to prevent patients from receiving unexpected medical bills.

Understanding the Denial

Hughes' insurer, Anthem, covered the ambulance costs and emergency department care, but denied coverage for her surgery and overnight stay. The reason given was that the surgery and hospital stay were not considered "medically necessary." This came as a shock to Hughes, especially since she was taking opioid painkillers and her car was totaled.

According to a 2023 study by the Kaiser Family Foundation, health insurance denials are fairly common, with insurers denying an average of 17% of claims in 2021. However, patients only appeal these denials once in every 500 cases. Hughes, being a rare exception, decided to challenge the decision.

The Role of the No Surprises Act

The No Surprises Act, passed in December 2020 and enacted in 2022, aims to protect patients from unexpected out-of-network bills after emergency care. However, Hughes found that not all aspects of her hospital stay were covered under this law.

She explained that patients are often not in a position to think strategically about their care immediately after an emergency. Even as a physician, she hadn't considered calling her insurance company to confirm authorization at an out-of-network facility.

The Backlog of Disputes

The No Surprises Act has faced challenges, with a backlog of hundreds of thousands of disputes between healthcare providers and insurers over the price of out-of-network services. According to the Centers for Medicare & Medicaid Services (CMS), there are 100 times as many disputes as initially projected. Providers, including out-of-network hospitals, are winning many of these disputes, leading to higher costs for everyone.

Resolving the Issue

After months of back-and-forth calls, help from her employer’s HR department, and media inquiries, the hospital "downgraded" Hughes' level of care and resubmitted the bill. Anthem then covered nearly $21,000 of the rebilled amount, leaving Hughes with only a $250 co-pay.

However, Hughes emphasized that patients are often left to navigate these disputes when they're least equipped to do so. She wished she had asked more pointed questions immediately after the initial denial, such as what criteria were used, who evaluated the case, and whether there was a peer-to-peer discussion between physicians.

Tips for Patients

Hughes shared some tips for patients facing similar billing battles:

• Ask your insurer for a detailed explanation in writing and confirm whether your care is being billed as inpatient or observation.
• Document every conversation you have with your insurer or provider, noting dates, times, and details.
• Loop in your employer’s HR or benefits team early; they may have direct contacts at insurance companies and can help connect you with resources.
• File a formal appeal with your insurer or request an external review through your state’s insurance department if you believe your care was wrongly denied.
• Request a temporary payment hold if the balance is sent to collections while your claim is still under review.

By following these steps, patients can better navigate the complex world of medical billing and ensure they receive the care they need without unnecessary financial burden.