His hearing input was received early. But he’s still getting a whopping $139,000 in debt

Caitlyn Mai woke up one morning in middle school unable to stand and deaf in one ear, the result of an infection that affected one of the nerves. his cranial. Although his composure was restored, the case did not return.

As he grew older, he learned to endure—but it wasn’t easy. With only one working ear, he had no idea where the sounds were coming from. He couldn’t walk with groups of people in conversation—at a social gathering or at work—so he learned to read lips.

For years, insurers wouldn’t approve cochlear implants for single-sided deafness because of concerns that it would be difficult to train the brain to control the signals from the ear. attentive and sensitive with the help of insertion. But research into the devastating effects of single-sided deafness and improvements in techniques have changed all that.

So Mai, now 27, and living near Oklahoma City, was thrilled last fall when she received a pre-authorization letter from her insurance that said she had coverage for the surgery. with a cochlear implant.

He underwent successful outpatient surgery to implant the device in December, and soon after was eager for therapy to get his brain used to its new abilities.

«It was amazing,» he said.

Then the bill came.

Patient: Caitlyn Mai, who is insured through her husband’s work is HealthSmart, which is owned by UnitedHealth Group.

Medical services: cochlear implant surgery, including the operating room, anesthesia, surgical equipment and drugs.

Service provider: SSM Health Bone & Joint Hospital St. Anthony, an Oklahoma City orthopedic hospital that is part of SSM Health, a Catholic health system in the central US.

Total fee: $139,362.74 – or, with the «fast payment rate» if he paid about two months after the surgery, $125,426.47.

What it offers: Providers and insurers often disagree about how the bill is submitted or written, and while they deal with it (or not), the patient is left holding the bag, sometimes facing big debts.

«I almost had a heart attack when I opened the account,» Mai said of the first monthly error, which came in late December. He said he was so upset that he left work to investigate. Before the surgery, «I even checked that all the hospitals and doctors were online and that I met my deductible,» he said.

Although she had never been threatened with her bill being sent to collections, she said she was worried about that possibility when similar bills arrived in January, February and March with ominous warnings that «your money is gone.»

Mai said she first called the hospital’s billing office but the representative only told her that the appeal was denied and the representative did not know why. Mai called her insurance, and the representative there said the hospital didn’t adequately report their charges or include billing codes. He then called the hospital and told them exactly what his insurance said needed to be done to settle the bill, as well as the name and number of the insurance agent he would fax.

When her insurance company told her a week or two later that it hadn’t received the corrected letter, Mai said, she called the hospital again — again.

He said: «I said, ‘I’ve done your work for you – now can you take it from there?’

Mai said the hospital worker promised to fax a corrected bill, said in two to three weeks. «How long does it take to send a fax?» he asked himself. He said he asked to speak to the manager and was told that the person was not there but that he would call him. No one did.

After receiving another bill for $139,000 in late March, Mai said, she went back to her insurer, but the agent said she had not received an updated bill.

Finally, he said, he told the hospital to «just send it to me and I’ll send it.» This time, he transferred the debt to his insurance company himself. But in late March, he received another bill demanding the full amount — and offered a $11,000-a-month payment plan.

Mai said she met her own out-of-pocket expenses and, with the pre-authorization in hand, expected the surgery to be fully covered.

SSM Health did not respond to multiple requests for comment on why it charged Mai.

Elisabeth Ryden Benjamin, vice president of health initiatives at the New York Public Service Association, an advocacy group, said: «It’s upsetting that patients end up making decisions. «And it’s upsetting that providers they are allowed to bill patients while dealing with insurance.»

Indeed, more and more patients are stuck with bills as insurers and hospitals spend more time arguing in the trenches, reports show. A recent report by Crowe, an accounting firm that works with many hospitals, found that more than 30% of claims submitted to commercial insurers early last year were unpaid for more than 90 days, something that surprising compared to the low rates of such delays with Medicare – 12% for inpatient claims and 11% for outpatient claims.

Crowe’s report found that a specific reason for denying claims was cited 12 times the rate of commercial insurers like Medicare: that they need more information before they can process the proposal. Such a request allows insurers to circumvent the laws of many states that require claims to be paid within 30 to 40 days, by pretending to give health plans the right to delay payment.

In a separate analysis, the American Hospital Association complained that the increase in insurance denials and delays «strains hospital resources» and «prevents necessary medical care.»

But perhaps no one is as badly injured as the patient, who carries the bills and believes they have to pay – especially when the mistakes are printed «in the past» and have discounts for immediate payment or interest-free repayment plans. «The stress and anxiety was huge,» Mai said.

Caroline Landree, a spokeswoman for UnitedHealth Group, said the insurer can only pay Mai’s claims «after receiving a detailed bill from her provider.»

«We encourage our members to contact their insurance card number for more information on the status of payments,» he added.

Conclusion: Mai estimated that she spent at least 12 hours on the phone doing tasks that would normally fall to a hospital billing clerk – making sure the bill was written as needed and that insurance had what it didn’t. want to make a payment.

More than 90 days after her surgery, after Mai received four alarmingly large bills, her insurance finally paid the claim. Mai didn’t owe anything.

He added: «I have not received a call from the manager until today.»

Takeaway: It is not uncommon for an insurer to delay paying a claim until they receive a credit score. Providers sometimes use billing methods to increase revenue, and studies show that more than half of hospital bills are in error. But research also suggests that entrepreneurs tend to drag their feet, cheat on codes and fees – and, in doing so, delay payments and withhold money.

Medical billing experts say it may not seem right for patients to receive bills while the process is underway but it is probably legal.

«The rules say, treat the patient harmlessly,» Benjamin said. «What we didn’t say was, don’t send them a bill.» He also said that it is not fair for patients to be forced to work on their own between providers and insurers who should negotiate.

What should the patient do? Step one: Don’t pay a bill (without a copay or coinsurance) for care or services covered by insurance. Call the health care provider and explain that they should take their bill to the insurer.

Second, ask the supplier to send a formal bill with all the billing codes used; then check it for errors. As a patient, you would know that you have never had an MRI, for example. Your insurance will not.

If additions to the Monthly Bill are any indication, many patients these days find themselves confused between providers and insurers to get bills settled and paid.

«Bravo for Ms. Mai for having the strength to stay with it and find a solution,» Benjamin said.

KFF Health News is a national newsroom that produces in-depth journalism on life issues and is one of the main programs operating in KFF – an independent source of health policy research, polls and journalism.

Emmarie Huetteman of KFF Health News edited the digital story. Taunya English and Simone Popperl of KFF Health News, along with Will Stone of NPR, edited the audio story.