番茄社区

One day in March 2020, during the height of the pandemic, Melinda Wenner Moyer's daughter, Jojo, in the driveway and cut her forehead on a rock.

After a quick consult with their primary care doctor, who said the 5-year-old needed stitches, and a trip to a nearby urgent care, which didn't think they could do the procedure without scarring, the mother and daughter set out for the emergency department. It was a 40-minute drive away, in Westchester, New York.

They went to the Maria Fareri Children's Hospital's emergency room. Moyer requested an on-call plastic surgeon, because someone had advised her to do so in a situation that called for stitches.

When the doctor, Anthony Alessi, DMD, MD, came in after a wait, the visit was quick: "He just stitched up her forehead, it took like, five minutes," Moyer said. "And then -- now I have this bill."

Moyer got Alessi's bill -- which listed a Los Angeles P.O. Box rather than a New York office -- a year and a half after the visit.

It totaled $21,500 -- $17,000 for the procedure, and $4,500 for the emergency department visit.

"THIS ACCOUNT IS SERIOUSLY PAST DUE, PLEASE CONTACT OUR OFFICE IMMEDIATELY," a note on the bill read.

Moyer was shocked: "I was not expecting that this morning."

After all, she thought, her insurance, UnitedHealthcare, covers ED visits, as they had in the past. When they left that day with 10 stitches in Jojo's forehead, "I didn't think about it at all. I assumed it was 100% covered."

But it wasn't that simple. Emergency physicians or doctors on call often aren't employed directly by the hospital. They can be contractors who are out-of-network for a patient's insurance, even if the hospital is in-network. The doctors or the staffing agencies that employ them negotiate with insurance companies for payment, while hospitals can send insurers separate bills for their part of the work.

In this case, Alessi had submitted a claim to UnitedHealthcare four times, according to Explanation of Benefits statements that Moyer shared with 番茄社区. Those claims were rejected by the insurance company all four times for what they said was "an incorrect or inappropriate primary diagnosis code."

Failing to get payment from the Moyers' insurance, Alessi's office passed the bill on to the Moyers themselves -- a practice known as "surprise billing."

Regulators have tried to address these bills, passing state and federal legislation that's supposed to protect patients from enormous charges for emergency services. The gives patients a way out of the bills, while insurers and providers, if they cannot agree on payment, go through an independent resolution process.

New York State law also to be "protected from surprise bills when treated by a non-participating (out-of-network) doctor at a participating hospital or ambulatory surgical center in their health plan's network" using a similar process.

It's not clear if the New York state law applies to the Moyers' employer-issued insurance plan, and because federal laws haven't taken effect yet, the Moyers may still end up with a big bill.

On Wednesday, Moyer called UnitedHealthcare to ask whether she was indeed responsible for the sum. The claims representative explained that Alessi's office still needed to provide additional information, but that the insurer would continue to process the claim.

"This $21,500 is actually not your responsibility," a UnitedHealthcare representative told Moyer.

From the bill, however, it appeared that it was. Moyer herself is a science journalist, and even for someone who knows the healthcare field better than most, the charge was still mystifying.

"How do people who do not have any background in ... healthcare or health ... manage this and navigate this?" she said. "It's so hard."

The insurer said Alessi's office needed to re-submit the bill with different codes. As the codes stood, they would duplicate claims that were already paid out. The hospital had asked for $683 and UnitedHealthcare had paid $267.

UnitedHealthcare said they had communicated the problem to Alessi's office and they were still waiting to hear back.

A billing representative for Alessi's office said they had submitted a claim to UnitedHealthcare and hadn't heard that they needed to resubmit different information.

When asked why they sent the bill, Alessi's representative said the "purpose is to send her a statement so she can confirm she had received this service with this doctor, and she can call her insurance carrier, and then we can go from there."

The representative said she needed to leave a paper trail for the negotiation to move forward. It wouldn't have worked, she said, to explain this to Moyer.

"If I called her and said 'this is the balance in full,' she might think 'okay, this is a scam,'" the representative told 番茄社区.

Instead, the bill arrived with the overdue notice.

"Clearly that was a bill and they were hoping I would pay it," Moyer said.

The UnitedHealthcare claims representative acknowledged to Moyer that Alessi is indeed an out-of-network provider who would "have the right to pass the bill to you guys, since you are the patient, and they don't have a contract with United Healthcare."

UnitedHealthcare said it would wait for the claim to be re-submitted correctly, and then negotiate with the physician: "Whatever amount they agree upon, then that's the amount that we are going to cover," the UnitedHealthcare representative told Moyer.

But depending on what the negotiated amount is, the Moyers may find themselves once again hit with a huge bill.

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