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This past February, when physician Dr. Lauren Hughes headed to her Denver clinic, she was shocked to end up dealing with her own emergency - and the hospital bill that came with it.

Another driver T-boned her Subaru. She was raced to the nearest emergency department at Platte Valley Medical Center.

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Hughes agreed to surgery for a broken ankle and deep cut to her knee. She would have advised the same for any of her patients; it would be routine.

What wasn't routine was what came next: a $63,976.35 hospital bill.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” she told The Washington Post.“It's crazy.” (1)

It turned out her insurance didn't cover inpatient treatment at Platte Valley. The hospital was out of network.

Even more shocking, she apparently didn't qualify for protection under the No Surprises Act.

This federal law expressly bans surprise hospital bills for most emergency services - even those provided by out-of-network hospitals.

Hughes is sharing her story to help others avoid a similar fate. Here's what happened.

The denial's in the details

Hughes' insurer, Anthem, covered the $2,400 ambulance costs and her care in the emergency department, but denied coverage for her surgery and overnight stay - explaining in a followup that her surgery and overnight stay were deemed not“medically necessary.”

Hughes couldn't believe it. After all, her car was totaled and she was taking opioid painkillers for the first time.

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Unfortunately, health insurance denial is fairly common, according to a 2023 study by the Kaiser Family Foundation, a health policy research organization.

Their study revealed that insurers in the Affordable Care Act marketplace denied an average of 17% of claims in 2021 - some rejecting upwards of 50% of submitted claims. (2)

Yet patients appeal those denials only once in every 500 cases.

Hughes - who happens to be director of the Farley Health Policy Center at the University of Colorado - is among the rare few who chose to challenge the decision.

She reached out to Kaiser Family Foundation (KFF) News to investigate. (3) (4)

Her case is instructive in how such denials may boil down to bureaucratic technicalities.

When contacted by KFF News, Anthem spokesperson Emily Snooks said that claims tied to a hospital admission must be approved or denied together as a bundle.

She suggested that if something that is medically necessary is bundled with something that is not considered necessary, the cost of that entire bundle of care will be denied.

“Anthem has consistently agreed that Ms. Hughes' ankle surgery was medically necessary,” she wrote, but not the hospital stay that followed her surgery.

“Because the ankle surgery was bundled with the inpatient admission, the entire claim was denied,” Snooks told KFF News.

Adding to the confusion, an Anthem representative told Hughes the outcome might have been different if the hospital had billed her stay as an observation visit, a classification used when patients are kept temporarily so staff can decide whether they need to be formally admitted.

What about the No Surprise Act

Hughes was surprised that not all aspects of her hospital stay were completely covered under the No Surprises Act - designed to protect patients from unexpected out-of-network bills after emergency care.

Passed by Congress in December 2020 and enacted in 2022, the law and related dispute resolution system designed to keep insurer and provider costs in check is already showing strain.

According to the Centers for Medicare & Medicaid Services (CMS), there is a backlog of hundreds of thousands of disputes between healthcare providers and insurers over the price of out-of-network services.

In fact there are 100 times as many disputes as the federal government initially projected when it passed the No Surprises Act. (5)

Concerningly, providers (including out-of-network hospitals) are winning many of these disputes, raising the overall cost of out-of-network services for everyone - including insurers, as the Niskanen Center policy think tank reports. (6)

Unfortunately, insurers are passing those higher out-of-network costs on to patients when they deem care is not“medically necessary,” Matthew Fiedler, a senior fellow at the Brookings Institution's Center on Health Policy, told the Washington Post.

No wonder 41% of Americans carry health-care debt. Many are driven to cut back on groceries, skip bill payments or empty their savings to stay afloat. (7)

How it ended

After months of back-and-forth calls, help from her employer's HR department and media inquiries from KFF Health News, the hospital“downgraded” her 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.

But as Hughes knows firsthand, patients are often left to navigate these disputes when they're least equipped to do so.

In her case, she was juggling calls to her family with arranging pet care, updating colleagues and her clinic while addressing her own physical and emotional needs, like“getting labs and imaging done - coming to grips with what just happened.”

If you're ever caught in a billing battle, don't accept the first denial.

UPMC, a health-care provider and insurer, recommends asking your insurer for a detailed explanation in writing and to confirm whether your care is being billed as inpatient or observation - that small distinction can make a huge difference in what's covered. (8)

Keep detailed notes of every call, date and name you speak with and loop in your employer's HR or benefits team early; they often have direct contacts at insurance providers.

You can also file a formal appeal or request an external review through your state's insurance department if you believe care was wrongly denied.

And if the balance ends up in collections, contact the hospital's patient advocate office to request a payment hold while your claim is under review.

Article sources

We rely only on vetted sources and credible third-party reporting. For details, see our editorial ethics and guidelines.

Washington Post (1 ); Kaiser Family Foundation (2, 3, 7 ); NPR (4 ); CMS (5 ); Niskanen Center (6 ); UPMC (8 )

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This article originally appeared on Moneywise under the title: Denver doctor hit by a car - then a $63K hospital bill after her insurer denied her care. How to avoid the same fate

This article provides information only and should not be construed as advice. It is provided without warranty of any kind.

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