On April 10, 2025, a number of hours after ending a hike in Sedona, Arizona, Jan Anderson began repeating herself.
“Did we hike this morning?” she requested.
“Yes, we hiked,” mentioned her husband, Steve Francks. “And you did really well.”
However 15 seconds later, she requested the identical query: “Did we hike today?”
Anderson, 65, a retired finance govt, doesn’t bear in mind any of it. She will recall what occurred that afternoon solely as a result of her husband began recording her on his cellphone.
“I was just on this nonstop loop,” she mentioned.
Virtually instantly, Francks knew one thing was incorrect. “Jan was out of it,” he mentioned.
He took her to an emergency room in Sedona, the place workers initially thought she is likely to be having a stroke. As a result of the power wasn’t totally outfitted to guage or deal with stroke sufferers, Francks mentioned, she was airlifted to a Phoenix-area hospital, the place she was admitted.
It turned out she wasn’t having a stroke. Her medical staff finally decided she was in all probability experiencing transient world amnesia, a uncommon, short-term, and benign reminiscence dysfunction.
The excellent news was that her signs didn’t final lengthy, and he or she has suffered no long-term results from the episode. It took about 24 hours earlier than she was capable of begin forming new recollections, and he or she was discharged the following day. Anderson and Francks, who break up their time between Sedona and Edmonds, Washington, returned to the Pacific Northwest just a few weeks later.
Then the invoice got here.
The Medical Service
The sudden confusion related to transient world amnesia can be an indication of a extra widespread neurological situation, so it’s necessary to rule out different doable causes — reminiscent of a stroke, for which well timed emergency care can spell the distinction between life and demise.
Anderson’s data present her care at Abrazo Well being’s Arrowhead Campus in Glendale, Arizona, included an electrocardiogram, which might detect underlying cardiac abnormalities, and imaging, which might rule out any vessel blockages that may trigger a stroke. She additionally underwent numerous lab checks generally used to diagnose a stroke.
The Invoice
$59,181: $35,302 for diagnostic/therapeutic imaging, $8,147 for laboratory companies, $8,146 for a particular care unit, $5,532 for EKG companies, and $2,054 for pharmacy. Anderson’s first invoice from Abrazo Well being mentioned she owed $15,312.43, citing an insurance coverage adjustment of $43,868.57, despite the fact that her insurer had not coated any of the fees.
Anderson mentioned her insurer coated separate fees for the ER and helicopter switch.
The Billing Downside: Communication Breakdown
The federal No Surprises Act bans out-of-network payments for many emergency companies, even when these companies are obtained at an out-of-network facility and aren’t preapproved by the insurer.
Meaning the price of Anderson’s hospital care ought to have been coated as if it have been in-network. On the time, she was insured by Molina Healthcare, by a plan bought on the federal Reasonably priced Care Act market.
However for a 12 months, Molina declined to pay for her care in Glendale, at one level arguing that her hospital keep required authorization when, and even earlier than, she was admitted.
“I can’t get anyone to resolve it,” Anderson mentioned. “It’s almost $60,000 hanging over my head.”
The primary downside arose about two weeks after she was discharged, when Abrazo Well being despatched Anderson a invoice indicating she was a self-pay affected person.
The hospital didn’t request her insurance coverage info at any level throughout her keep, Francks mentioned. He assumed, on the time, that his spouse’s monetary paperwork had been transferred from the ER in Sedona. It had not.
She known as the Glendale hospital and corrected the error.
Then, in late June, Anderson obtained discover from the hospital indicating she was not a Molina member.
“Your insurance company notified our office that the patient was not a covered member for the services provided by Abrazo Arrowhead Campus on the above referenced service date(s),” the discover mentioned. It confirmed the entire fees for her keep exceeded $59,000.
However when Anderson known as Molina to verify her protection, she mentioned, the insurance coverage firm assured her the declare was being processed.
That didn’t imply Molina was prepared to cowl her hospital invoice.
Anderson spent months making an attempt to resolve the stability. She filed complaints with members of Congress, the Arizona Division of Insurance coverage and Monetary Establishments, and the Workplace of the Insurance coverage Commissioner in Washington state.
In an October letter to Washington’s insurance coverage commissioner, an enchantment and grievance specialist for Molina wrote that the declare was denied as a result of “inpatient stays require prior authorization, or notification at the time of admission. No notification of admission or prior authorization was received from the hospital, so the claim was denied.”
It continued: “Molina covers out of network emergency services but since this was an inpatient admission authorization is required.”
Nicole Broadhurst, who focuses on medical billing points as CEO of a Tennessee affected person advocacy group, mentioned this dispute seems to relaxation between the insurer and the medical supplier.
She mentioned that Anderson’s insurance coverage info ought to have been transferred between the primary ER and the Glendale hospital. Because it wasn’t, Broadhurst mentioned, Anderson shouldn’t be held accountable for her hospital invoice. (Broadhurst was not concerned in efforts to resolve Anderson’s billing dispute.)
Sadly, Broadhurst mentioned, these conditions are “not uncommon, even though we have the No Surprises Act.”
The Decision
Anderson mentioned she was instructed by Abrazo Well being for months that it was working with Molina to resolve the invoice. She mentioned she was additionally instructed that even when Molina didn’t cowl the complete value of her hospital care, she wouldn’t be accountable for the stability — however she by no means obtained that assurance in writing.
In the meantime, Molina continued to uphold its determination to disclaim fee.
After KFF Well being Information contacted the insurer and the hospital with questions on her case, Molina instructed Anderson it had launched an inside overview of her declare, and a income director with Abrazo Well being instructed her the corporate was “treating this as a high-priority matter,” she recalled.
Anderson mentioned the income director for the well being system assured her that if Molina continued to disclaim fee, “the balance will be written off on the hospital’s end,” she mentioned. “I will not be responsible for any balance” — not even the $15,312.43 the hospital initially billed her after the hospitalization.
Linda Nofer, a spokesperson for Abrazo Well being, wouldn’t reply questions on Anderson’s invoice. In an announcement, she mentioned the hospital system is “committed to working closely with our patients to resolve billing questions and concerns.”
Molina spokesperson Caroline Zubieta wouldn’t talk about or reply to questions on Anderson’s case on the report.
The Takeaway
The flurry of insurance coverage paperwork and medical payments sufferers obtain after a hospital keep might be overwhelming — and will generally seem contradictory.
Broadhurst mentioned it’s necessary for sufferers to deal with the “patient responsibility” portion of an insurance coverage doc known as a proof of advantages.
Sufferers mustn’t pay a invoice if their clarification of advantages signifies they aren’t liable for the quantity charged.
On this case, Anderson had obtained a invoice from the hospital saying she owed cash. And her clarification of advantages from Molina confirmed she’d racked up greater than $59,000 in hospital fees.
However that doc additionally indicated her affected person legal responsibility was “$0.00.” Anderson mentioned the hospital was not pressuring her to pay the $15,312.43 invoice or any of the fees tied to her account, however she was apprehensive she would finally owe a big sum as a result of the fees remained unresolved for greater than a 12 months.
“The question I kept asking them was, ‘How much am I going to owe?’” mentioned Anderson, who’s now insured by Medicare. “It could be anywhere from that $15,000 adjusted amount to the full balance of $59,000.”
Broadhurst mentioned she tells sufferers dealing with related conditions to “send the hospital a copy of the EOB and ask them to correct the account to $0 patient responsibility.”
“Even if no one is actively trying to collect, I’d still push for written closure so it doesn’t keep hanging over them,” she mentioned.
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Submit’s Effectively+Being that dissects and explains medical payments. Since 2018, this sequence has helped many sufferers and readers get their medical payments lowered, and it has been cited in statehouses, on the U.S. Capitol, and on the White Home. Do you could have a complicated or outrageous medical invoice you need to share? Inform us about it!
