“Did we hike this morning?” she asked.

“Yes, we hiked,” said her husband, Steve Francks. “And you did really well.”

But 15 seconds later, she asked the same question: “Did we hike today?”

Anderson, 65, a retired finance executive, doesn’t remember any of it. She can recall what happened that afternoon only because her husband started recording her on his cellphone.

“I was just on this nonstop loop,” she said.

Almost immediately, Francks knew something was wrong. “Jan was out of it,” he said.

He took her to an emergency room in Sedona, where staff initially thought she might be having a stroke. Because the facility wasn’t fully equipped to evaluate or treat stroke patients, Francks said, she was airlifted to a Phoenix-area hospital, where she was admitted.

It turned out she wasn’t having a stroke. Her medical team eventually determined she was probably experiencing , a rare, temporary, and benign memory disorder.

The good news was that her symptoms didn’t last long, and she has suffered no long-term effects from the episode. It took about 24 hours before she was able to start forming new memories, and she was discharged the next day. Anderson and Francks, who split their time between Sedona and Edmonds, Washington, returned to the Pacific Northwest a few weeks later.

Then the bill came.

The Medical Service

The sudden confusion associated with transient global amnesia can also be a sign of a more common neurological condition, so it’s important to rule out other possible causes — such as a stroke, for which timely emergency care can spell the difference between life and death.

Anderson’s records show her care at Abrazo Health’s Arrowhead Campus in Glendale, Arizona, included an electrocardiogram, which can detect underlying cardiac abnormalities, and imaging, which would rule out any vessel blockages that might cause a stroke. She also underwent various lab tests commonly used to diagnose a stroke.

The Bill

$59,181: $35,302 for diagnostic/therapeutic imaging, $8,147 for laboratory services, $8,146 for a special care unit, $5,532 for EKG services, and $2,054 for pharmacy. Anderson’s first bill from Abrazo Health said she owed $15,312.43, citing an insurance adjustment of $43,868.57, even though her insurer had not covered any of the charges.

Anderson said her insurer covered separate charges for the ER and helicopter transfer.

The Billing Problem: Communication Breakdown

The federal No Surprises Act bans out-of-network bills for most emergency services, even if those services are received at an out-of-network facility and are not preapproved by the insurer.

That means the cost of Anderson’s hospital care should have been covered as though it were in-network. At the time, she was insured by Molina Healthcare, through a plan purchased on the federal Affordable Care Act marketplace.

But for a year, Molina declined to pay for her care in Glendale, at one point arguing that her hospital stay required authorization when, or even before, she was admitted.

“I can’t get anyone to resolve it,” Anderson said. “It’s almost $60,000 hanging over my head.”

The first problem arose about two weeks after she was discharged, when Abrazo Health sent Anderson a bill indicating she was a self-pay patient.

The hospital didn’t request her insurance information at any point during her stay, Francks said. He assumed, at the time, that his wife’s financial paperwork had been transferred from the ER in Sedona. It had not.

She called the Glendale hospital and corrected the error.

Then, in late June, Anderson received notice 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 notice said. It showed the total charges for her stay exceeded $59,000.

But when Anderson called Molina to confirm her coverage, she said, the insurance company assured her the claim was being processed.

That didn’t mean Molina was willing to cover her hospital bill.

Anderson spent months trying to resolve the balance. She filed complaints with members of Congress, the Arizona Department of Insurance and Financial Institutions, and the Office of the Insurance Commissioner in Washington state.

In an October letter to Washington’s insurance commissioner, an appeal and grievance specialist for Molina wrote that the claim was denied because “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 issues as CEO of a , said this dispute appears to rest between the insurer and the medical provider.

She said that Anderson’s insurance information should have been transferred between the first ER and the Glendale hospital. Since it wasn’t, Broadhurst said, Anderson shouldn’t be held liable for her hospital bill. (Broadhurst was not involved in efforts to resolve Anderson’s billing dispute.)

Unfortunately, Broadhurst said, these situations are “not uncommon, even though we have the No Surprises Act.”

The Resolution

Anderson said she was told by Abrazo Health for months that it was working with Molina to resolve the bill. She said she was also told that even if Molina did not cover the full cost of her hospital care, she would not be liable for the balance — but she never received that assurance in writing.

Meanwhile, Molina continued to uphold its decision to deny payment.

After 麻豆女优 Health News contacted the insurer and the hospital with questions about her case, Molina told Anderson it had launched an internal review of her claim, and a revenue director with Abrazo Health told her the company was “treating this as a high-priority matter,” she recalled.

Anderson said the revenue director for the health system assured her that if Molina continued to deny payment, “the balance will be written off on the hospital’s end,” she said. “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 Health, would not answer questions about Anderson’s bill. In a statement, she said the hospital system is “committed to working closely with our patients to resolve billing questions and concerns.”

Molina spokesperson Caroline Zubieta would not discuss or respond to questions about Anderson’s case on the record.

The Takeaway

The flurry of insurance paperwork and medical bills patients receive after a hospital stay can be overwhelming — and may sometimes appear contradictory.

Broadhurst said it’s important for patients to focus on the “patient responsibility” portion of an insurance document called an explanation of benefits.

Patients should not pay a bill if their explanation of benefits indicates they aren’t responsible for the amount charged.

In this case, Anderson had received a bill from the hospital saying she owed money. And her explanation of benefits from Molina confirmed she’d racked up more than $59,000 in hospital charges.

But that document also indicated her patient liability was “$0.00.” Anderson said the hospital was not pressuring her to pay the $15,312.43 bill or any of the charges tied to her account, but she was worried she would eventually owe a large sum because the charges remained unresolved for more than a year.

“The question I kept asking them was, ‘How much am I going to owe?’” said Anderson, who is now insured by Medicare. “It could be anywhere from that $15,000 adjusted amount to the full balance of $59,000.”

Broadhurst said she tells patients facing similar situations 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 said.

Bill of the Month is a crowdsourced investigation by 麻豆女优 Health News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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It was “just like a mosquito bite, nothing major, and I just scratched it,” said Toska, a political science professor.

Then she began to itch everywhere. She couldn’t see anything in the dark, so her husband shined his phone light on her.

She was covered in hives.

Because she also felt pressure in her chest, the family quickly went to an urgent care clinic. A doctor there recognized she was experiencing , a life-threatening, fast-moving allergic reaction.

The doctor rushed her to a room without checking her in, saw her blood pressure was low, and administered two epinephrine injections and IV fluids, Toska said. The itching stopped, and the tightness in her chest went away.

But the doctor said she needed to be monitored in an emergency room for at least two hours in case the reaction flared up again. Toska said the doctor insisted she take an ambulance to a nearby hospital, Atrium Health Lake Norman.

Minutes later, she found herself lying on a stretcher in the ER.

A doctor she described as “lovely” came in and spoke to her for no more than five minutes, Toska said. A nurse administered medicine through the IV line inserted at the urgent care clinic.

Toska was exhausted, but her mind was on her daughters. “I had two little kids who were scared, so I was playing with them and trying to distract them.”

After about an hour and a half, the doctor returned briefly, then the family went home, she said.

“That’s it,” Toska said. “Nothing happened at the ER.”

Then the bill came.

The Medical Service

Toska said the ER doctor reviewed her vitals and discussed her allergic reaction and what to watch for when she got home. She also received a dose of famotidine, a drug often used to treat an upset stomach that is also administered for allergic reactions.

The Bill

The in-network hospital system charged Toska’s insurer, Blue Cross Blue Shield of North Carolina, $6,746.50 for the ER visit, including $20.60 for the famotidine and $6,445.60 in “critical care” charges. Toska, who had not met her insurance deductible, was responsible for a $150 copay and $3,100.24 of the charges.

The Billing Problem: Critical Care

“Paying $3,100.24 for literally sitting in the ER entertaining my kids for an hour and a half feels kind of incredible,” Toska said.

Medical providers in the United States use a uniform coding system to bill for procedures and services. Most of Toska’s ER charges stemmed from Atrium Health’s use of two billing codes for “critical care” 鈥� one for 30 to 74 minutes of care, at $5,617.85 (code 99291), and another for an additional 30 minutes (code 99292), at $827.75.

According to the coding system, critical care is when a doctor “directly” provides at least 30 minutes of care to a patient with “a probability of imminent or life-threatening deterioration.”

According to the ER’s visit notes, which Toska shared with 麻豆女优 Health News, Toska told the doctor there she was feeling “significantly better” when she arrived, and the doctor reported providing 90 minutes of personal critical care.

Anaphylactic shock is treated under code 99291, according to the . Though Toska’s symptoms may have indicated she was no longer in shock, treatment guidelines require at least two hours of monitoring, said Arjun Venkatesh, the chair of emergency medicine at the Yale School of Medicine.

With anaphylaxis, “some people are going to progress and require admission to the ICU, and some won’t,” Venkatesh said.

Toska was under critical care because of what could have happened, not what did happen, Venkatesh said. Hospitals use the same billing codes for the ER visit, whether a patient’s condition deteriorates or not.

“The billing rules are not built around this,” Venkatesh said.

Laura Eberhard, a spokesperson for Blue Cross Blue Shield of North Carolina, said Toska’s claims “were submitted by the provider using critical care codes, which represent a higher level of severity and reimbursement, and were processed in-network under the terms of the member’s plan.” She did not answer questions about whether Blue Cross Blue Shield negotiated the charges.

A spokesperson for Atrium Health did not answer questions from 麻豆女优 Health News about Toska’s visit.

The Resolution

Toska said she called Blue Cross Blue Shield of North Carolina, trying to get a better explanation for why the bill for so little hands-on care was so high.

“The doctor determines the severity of the situation, and that’s the code we have,” the insurance representative said, according to Toska’s recollection. “This is critical care, and that’s what it costs.”

After Toska contacted the hospital, Atrium Health’s Audit and Appeals Department replied in a letter that the critical care designation was “based on the presenting problem that brought you to the emergency room, the treatment provided, and the nursing staff that took care of you.”

“It also includes the room, supplies, and equipment utilized during the visit,” the letter continued. “The charge is not based on time spent in the facility or with clinicians.”

Asking why the ER visit cost so much was more a matter of principle than necessity, she said, though she thought back a few years to a time when it would have been much harder for her to pay.

“The system is so broken,” Toska said.

The Takeaway

“Her experience is, sadly, very typical,” said Barak Richman, a professor of business law and co-director of the Health Law and Policy program at George Washington University. “Once you are brought onto the train of health care delivery, you have no control over where the stops are.”

Emergency rooms 鈥� for many the for medical care 鈥� are notorious for high costs, he said, adding that insurance companies should always try to negotiate critical care codes.

Toska was fortunate to dodge another problem common in emergencies: The bill for taking an ambulance to the ER was about $275, she said, notable since ambulance rides frequently result in bigger bills that may not be covered by insurance.

Patients can dispute charges with their insurance and the hospital. Like Toska, they should come to the phone with an itemized bill, medical records, and any other relevant documents, such as explanation-of-benefits statements.

Regardless of whether that’s a fight they can win, some who see one ER bill , especially if it might put them in .

In early March, Toska had a second allergic reaction. “OK,” she recalled thinking, “Do I go get the EpiPen? Do I go to the ER and get another massive bill?”

She decided against the trip and took Benadryl instead.

Bill of the Month is a crowdsourced investigation by 麻豆女优 Health News and that dissects and explains medical bills.聽Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

This <a target="_blank" href="/health-industry/er-monitoring-anaphylactic-shock-allergic-reaction-bill-of-the-month-april-2026/">article</a&gt; first appeared on <a target="_blank" href="">麻豆女优 Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

His primary care doctor referred him to a rheumatologist, who diagnosed psoriatic arthritis. She advised Mishra that while there’s no cure, there were many new medicines that could keep the autoimmune disease in check, and she recommended one, Otezla.

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

But by September he was in so much pain that he agreed to try a starter pack provided by Otezla’s manufacturer, Amgen. It worked: The skin lesions disappeared, and the joint pain that kept him up at night dissipated. He was sold.

His rheumatologist got approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment assistance program. Having enrolled other patients, she told Mishra the copay card, similar to a credit card, should last a year, he said, shielding him from the drug’s high list price: around $5,000 for a 30-day supply, .

He said the doctor explained that, in her patients’ experience, insurers and their pharmacy benefit managers negotiated a deeply discounted price with Amgen 鈥� she estimated $1,400 to $2,200 a month. Patients paid a percentage of that amount, their “patient responsibility,” using the copay card.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got the message,” he said.

He added that the doctor reassured him about the cost. “She said: 鈥榊ou shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug 鈥� before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx 鈥� another subsidiary of the same parent company, UnitedHealth Group 鈥� showed it did not provide a negotiated discount and covered just $308.34 of the full $5,253.85 charge for a 30-day supply. The charges for the second month depleted the copay card and left Mishra owing the balance.

The Billing Problem: Copay Card 鈥楾ug-of-War’

Copay assistance programs are part of a “tug-of-war between drug manufacturers and insurers,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies the pharmaceutical industry.

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for instance, do not count the money from a copay program toward a patient’s deductible.

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements read, in tiny letters. The amount the copay card covered “was not applied towards your Deductible and Out of Pocket Maximum.”

Caroline Landree, a spokesperson for UnitedHealthcare, said that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”

In an emailed statement, Elissa Snook, a spokesperson for Amgen, expressed a different view of who was responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine.”

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

Insurers insulate themselves and their customers from those higher prices through pharmacy benefit managers’ negotiated discounts. They might, for example, designate certain drugs as preferred medications for plan members in exchange for the manufacturer agreeing to a significant price reduction.

Manufacturers’ copay assistance programs offer another way for patients to avoid paying full price. The assistance is intended to encourage patients to choose an expensive, brand-name drug 鈥� not one that “treats the same condition that the insurer has gotten for a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug pricing.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen has of its generic competitors, ensuring the brand-name drug has patent protection until 2028. Generic versions are available overseas and in Canada, where patients can purchase it in some cases for .

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing his medicine while he was there.

The Resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

In September, he paid for the first month’s supply of Otezla with the copay card. But paying for October’s supply emptied the card 鈥� which he originally expected to last a year 鈥� and he said he used his HSA to pay for the roughly $400 that remained.

But wary of what the drug would cost in November and December, Mishra said, he tried to spread out the pills he had left from the starter pack and the first two months’ supply. He skipped some days and took only half of the prescribed dose to stretch the supply for two more months, knowing he would get a new copay card with the new year. Many of his symptoms returned, he said.

In January, he got another copay card, good for $9,450, which again wasn’t sufficient to pay for two months’ supply. He again paid the remaining balance in February from his HSA to count toward his $5,000 annual deductible. This time he owed $550, he said.

Mishra said his symptoms have resolved. With no clue what he’d be charged for March’s supply, he called UnitedHealthcare in late February and was told he would need to pay $4,450 for the month to meet his out-of-pocket maximum, he said.

But he said he pressed the representative further, asking why UnitedHealthcare doesn’t have a negotiated price. It does, they told him. “Actual price is $6,995.36.”

The Takeaway

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

On the one hand, they encourage patients to use brand-name or expensive drugs that are off insurers’ formularies, or lists of preferred, covered drugs. On the other, many patients couldn’t afford prescribed medicines without them.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them an end run around its attempts to bring down drug spending.

Using a copay card has gotten trickier as insurers push back. First, patients need to understand whether there is an annual dollar or time limit on the card and how it works with their insurance. Otherwise, they risk ending up reliant on a drug they can’t afford.

Less expensive drugs often can suffice. For example, there are a number of medicines to treat psoriatic arthritis, some of which may be cheaper or have better coverage from a particular insurer. Patients should ask their doctors whether cheaper medicines will work.

It also can help patients to consider their prescriptions when they select a health plan. Landree, of UnitedHealthcare, said Mishra could have selected a plan for 2026 that would have covered Otezla for a $100 copay each month, though that would have meant a higher premium.

“Personally I’m not in financial distress 鈥� I can afford it,” Mishra said. “But it was sticker shock, and it just doesn’t seem right.”

Bill of the Month is a crowdsourced investigation by 麻豆女优 Health News and  that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

This <a target="_blank" href="/health-care-costs/expensive-drug-copay-card-discount-bill-of-the-month-february-2026/">article</a&gt; first appeared on <a target="_blank" href="">麻豆女优 Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.

During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in-network.” She assumed that meant her policy would cover the appointment.

Then the bill came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

Tuszynski was baffled that care for a patient’s eyes would not be covered by vision insurance. She said she didn’t realize that insurers can have contracts with eye clinics to provide some services but not others.

UnitedHealthcare spokesperson Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. “I looked up my eye doctor, and it’s the same thing,” she said in an interview with 麻豆女优 Health News.

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

Casey Schwarz, senior counsel for education and federal policy at the nonprofit , said such complications frequently come up when Medicare Advantage members try to use their insurance at eye clinics or dental offices.

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries . Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz said.

The Resolution

After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called to complain to federal officials. She also wrote to 麻豆女优 Health News, which asked the insurer about the case.

UnitedHealthcare eventually agreed to cover the bill as if the service had been in-network. “In good faith, we made an exception,” Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered, because the clinic remains out-of-network for such services, Sergel said. “It doesn’t sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

She said she lost sleep over the dispute and felt that it shouldn’t have taken so much effort to obtain a fair outcome. “It’s just been a horrible, difficult whirlwind,” she said.

The Takeaway

Schwarz said regulators should require insurance companies to clearly explain to customers and care providers how different procedures and services will be covered under vision, dental, and health plans. “They’re tricky,” she said.

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with 麻豆女优, a health information nonprofit that includes 麻豆女优 Health News, noted that Medicare’s website that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but information about provider networks is not always correct,” Neuman said. “Errors can come at a cost to enrollees, unless they are willing and able to take on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

She knows her $340 bill was much smaller than the medical debts many other people face. But she said it was a serious amount of money to her, and she was glad she objected to the insurer’s contention that the bill shouldn’t be covered.

“I have a strong feeling about right and wrong 鈥� and this is just wrong,” she said.

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying no separate premium for her old Medicare Advantage plan.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.

However, she no longer has insurance coverage for eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

Bill of the Month is a crowdsourced investigation by  and  that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

This <a target="_blank" href="/health-care-costs/medicare-advantage-eye-care-wisconsin-bill-of-the-month-january-2026/">article</a&gt; first appeared on <a target="_blank" href="">麻豆女优 Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

After Susannah Reed-McCullough’s husband died in 2018, she and their young daughters continued to receive health insurance through his job as a firefighter in Maryland.

Then, in 2024, she got an unexpected medical bill: $377 for a checkup for one of her children the previous fall. Reed-McCullough said she called the doctor’s billing department and learned the insurance company had dropped the children’s coverage.

The drop turned out to be a mistake. But Reed-McCullough said she was forced to act as the go-between for her late husband’s human resources department and their insurer — all while worried about her daughters’ being uninsured.

In this installment of InvestigateTV and 麻豆女优 Health News’ “Costly Care” series, Caresse Jackman, InvestigateTV’s national consumer investigative reporter, explores how administrative errors can leave patients on the hook for medical bills they shouldn’t owe, sometimes with few options to correct a problem they didn’t create.

Jackman interviewed Elisabeth Rosenthal, senior contributing editor at 麻豆女优 Health News, who said accidental coverage drops are “a common problem” in need of attention from state regulators.

“People make mistakes, systems make mistakes, and they should be held responsible for them, not the patient,” Rosenthal said.

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Treatment for a Florida Medicaid enrollee’s cost nearly $78,000 鈥� about as much as surgery for an uninsured Montana woman’s .

In 2025, these patients were among the hundreds who to investigate their medical bills as part of its “” series.

Insured and uninsured. Job-based and government-funded. Comprehensive and short-term. Part of a sharing ministry. So many people with different health insurance situations asked the same questions: Why do I owe so much? And how am I going to afford it?

As millions of Americans grapple with the rising cost of health insurance next year, the “Bill of the Month” series is approaching its eighth anniversary. Our nationwide team of health reporters has analyzed almost $7 million in medical charges, more than $350,000 of that this year.

Of this year’s 12 featured patients, five had their bills mostly or fully forgiven soon after we contacted the provider and insurer for comment.

Our mission, though, is to empower every patient with the information needed to understand, manage, and 鈥� if push comes to shove 鈥� fight their own medical bills. Here are our 10 takeaways from 2025.

1. Most insurance coverage doesn’t start immediately. Many new plans , so it’s important to maintain continuous coverage until the new plan kicks in. One exception: If you lose your job-based coverage, you have 60 days to opt into . Once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.

2. Check out your coverage before you check in. Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and . Call your insurer 鈥� or, for job-based insurance, your human resources department or retiree benefits office 鈥� and ask whether there are exclusions for the care you need, including per-day or per-policy-period caps, and what you can expect to owe out-of-pocket.

3. “Covered” does not mean insurance will pay, let alone at in-network rates. Carefully read the fine print on network gap exceptions, prior authorizations, and other insurance approvals. The terms to certain doctors, services, and dates.

4. Get a cost estimate in writing for nonemergency procedures. If you object to the price, . And if you’re uninsured and receive a bill that’s $400 or more than the estimate, the federal Centers for Medicare & Medicaid Services has a .

5. Location matters. Prices can vary depending on where a patient receives care and where tests are performed. If you need blood work, ask your doctor to send the requisition to an in-network lab. A doctor’s office , for instance, may send samples to a hospital lab, which can mean higher charges.

6. When admitted, contact the billing office early. If possible, when you or a loved one has been hospitalized, it can help to speak to a billing representative. Ask whether the patient has been fully admitted or is being kept under observation status, as well as whether the care has been And while there may be no choice about , if a is recommended, you can ask whether the ambulance service is in-network.

7. Ask for a discount. Medical charges are almost always higher than what insurers would pay, because providers expect them to negotiate lower rates. You can, too. If you’re uninsured or underinsured, you may be eligible for a .

8. There’s help available for Medicaid patients. If you get a bill you , file a complaint with your state’s Medicaid program and, if you have one, your managed-care plan. Ask whether there is a caseworker who can advocate on your behalf. A legal aid clinic or consumer protection firm specializing in medical debt can also help file complaints and communicate with providers.

9. Your elected representatives can help, too. While a call from a state or federal lawmaker’s office may not get your bill forgiven, those officials often have with insurance companies, local hospitals, and other major providers 鈥� and advocating for you is their job.

10. When all else fails 鈥� you can !

Most Insurance Covers IUDs. Hers Cost More Than $14,000.

The Affordable Care Act requires most insurance plans to cover preventive care, including many forms of contraception, without cost to patients 鈥� but not if they’re “grandfathered” plans, which predate the law.

By Julie Appleby Jan. 31, 2025

A Runner Was Hit by a Car, Then by a Surprise Ambulance Bill

A San Francisco man had friends drive him to the hospital after he was hit by a car. Doctors checked him out, then sent him by ambulance to a trauma center 鈥� which released him with no further treatment. The ambulance bill? Almost $13,000.

By Sandy West Feb. 28, 2025

He Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000.

After leaving his job to launch his own business, an Illinois man opted for a six-month health insurance plan. When he needed a colonoscopy, he thought it would cover most of the bill. Then he learned his plan’s limited benefits would cost him plenty.

By Julie Appleby March 28, 2025

The Patient Expected a Free Checkup. The Bill Was $1,430.

Carmen Aiken of Chicago thought their medical appointment would be covered because the Affordable Care Act requires insurers to pay for a long list of preventive services. But after the appointment, Aiken received a bill for more than $1,400.

By Samantha Liss and Lauren Sausser April 30, 2025

A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78,000.

Federal law says Medicaid must cover out-of-state emergency care. But a Florida man got a five-figure bill after a South Dakota hospital declined to charge his state’s Medicaid program.

By Arielle Zionts May 29, 2025

A Texas Boy Needed Protection From Measles. The Vaccine Cost $1,400.

A family living in Galveston was surprised to be charged thousands of dollars for immunizations for their children. Their insurance plan didn’t cover the shots, and the cost of the measles vaccine in particular was more than five times what health officials say it goes for in the private sector.

By Julie Appleby June 30, 2025

A Tourist Ended Up With a Wild Bat in Her Mouth 鈥� And Nearly $21,000 in Medical Bills

Health insurance generally doesn’t cover treatment for injuries sustained shortly before a customer buys a policy. A Massachusetts woman found that out the hard way.

By Tony Leys July 31, 2025

An Insurer Agreed To Cover Her Surgery. A Politician’s Nudge Got the Bills Paid.

A kindergartner in Missouri needed eye surgery. Her insurer granted approval for her to see a specialist nearby, yet her parents were confused when they still owed more than $13,000. Then her uncle, a former state senator, reached out to a colleague who contacted the hospital and the insurer.

By Cara Anthony Aug. 26, 2025

She Had a Broken Arm, No Insurance 鈥� And a $97,000 Bill

Deborah Buttgereit knew piecing together the broken bone in her elbow would be expensive. But complications the doctor deemed a surprise, midsurgery, drove the total bill tens of thousands of dollars above the original estimate.

By Katheryn Houghton Sept. 24, 2025

Doctor Tripped Up by $64K Bill for Ankle Surgery and Hospital Stay

A doctor in Colorado became the patient after an accident totaled her car and sent her to the operating room. The hospital kept her overnight, but her insurer stopped paying after she left the emergency room.

By Julie Appleby Oct. 29, 2025

Not Serious Enough To Turn on the Siren, Toddler’s 39-Mile Ambulance Ride Still Cost Over $9,000

After her son contracted a serious bacterial infection, an Ohio mother took the toddler to a nearby ER, and staffers there sent him to a children’s hospital in an ambulance. With no insurance, the family was hit with a $9,250 bill for the 40-minute ride.

By Tony Leys Nov. 25, 2025

Scorpion Peppers Caused Him 鈥楥rippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Homemade hot sauce sent a Colorado man to the emergency room with what he called “the worst pain of my life.” But stomach cramps were only the beginning. Two years later, the bill came.

By Elisabeth Rosenthal Dec. 19, 2025

Photographers

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Kruzic was seen immediately because hospital staff members were pretty sure he had appendicitis. They inserted an IV, called a surgeon, and sent him off for a scan to confirm the diagnosis.

But the scan showed a perfectly normal appendix and no problems in his abdomen. Doctors racked their brains for other possible diagnoses. Could it be a kidney stone? Gallstones? Here was a 37-year-old man in agony, but nothing really fit.

Then, someone asked what Kruzic had eaten the night before. He said he’d consumed tacos with some hot sauce that he’d made from a kind of scorpion pepper, grown from seeds he ordered from a chile pepper research institute.

The peppers measure over 2 million Scoville heat units on the spiciness scale, he noted, compared with a jalapeño at up to 8,000 or a habanero at 100,000 to 350,000.

The peppers are among “the world’s hottest, incredibly hot,” Kruzic said. “Delicious.” He loves spicy food and had never had a problem with it, but apparently this was just too much burn for his digestive system.

Kruzic spent much of the night on a gurney in the ER. After about four hours, the pain decreased, and he was sent home with medicine to treat nausea and vomiting.

Then the bill came 鈥� about two years later.

The Medical Procedure

Kruzic underwent blood work and a CT scan of his abdomen during his ER visit for acute abdominal pain.

Consuming very spicy foods painful inflammation and irritation of the digestive system. The discomfort typically resolves on its own.

The Final Bill

$8,127.41, including $5,820 for the CT scan. Kruzic paid $97.02 during his visit to the hospital, which was in-network under his insurance. After insurance payments and discounts, he owed $2,460.46 鈥� the remainder of the $1,585.26 he owed toward his plan’s deductible and $972.22 he owed in coinsurance.

The Problem: Ghost Bills From Visits Past

This September, Kruzic received a bill for his pepper-induced ER visit in 2023.

Unfortunately for patients, there are no uniform rules for timely billing.

Anticipating a bill, Kruzic repeatedly checked the hospital’s online portal, as well as that of his insurer, UnitedHealthcare. He noted that the insurer said the claim had been processed shortly after his treatment. For about eight months, he kept checking the hospital portal’s billing section, which indicated he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he owed nothing, that was the case.

It is unclear what caused the nearly two-year delay. At least part of the problem seems to have involved protracted disagreements between the insurer and the hospital over how much his visit should have cost.

Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement to 麻豆女优 Health News: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations Department to rectify the underpayments.”

Asked why it had taken two years, she cited a reorganization at UnitedHealthcare and a change in the insurer’s representative assigned to the case.

But UnitedHealthcare contested that view. “This was paid accurately,” said Caroline Landree, a spokesperson for the insurer.

But those explanations don’t satisfy Kruzic, a geological consultant: “Receiving a bill two years after the service wouldn’t fly in any other industry. We could never contact a client two years after we completed a project and say, 鈥楤y the way, we missed this charge.’”

“How could this be considered anything but surprise billing?” he added.

The federal No Surprises Act doesn’t protect against all types of medical bills that patients find surprising. It primarily protects patients from out-of-network charges when they visit an in-network hospital, or in an emergency.

But in medical billing, what’s legal and what’s reasonable are two very different issues.

“The bill certainly sounds outrageous,” said Maxwell Mehlmen, co-director of the Law-Medicine Center at the Case Western Reserve University School of Law. “The question is whether it’s legal.”

That, he said, “is a matter of state law and the terms of the insurance policy and the agreement between the hospital and the insurer.”

In Colorado, there are extensive regulations about how long health care providers have to file a claim and . For instance, claims for Medicaid patients must be filed from the date of service. For patients with private insurance, the terms may be outlined in their insurers’ contracts with individual providers.

If a hospital and the provider and insurer were working out payment in good faith, then a patient can be billed for their share of the costs years later.

The Resolution

Within hours of 麻豆女优 Health News contacting the hospital’s media relations department for this article, Kruzic got a call from a hospital executive telling him his bill had been adjusted to zero.

Blaming administrative changes at the insurer, Radford Foster of CommonSpirit said that UnitedHealthcare had taken so long to properly pay the bill that the hospital couldn’t collect from the patient. She said that Kruzic’s statement balance “was to be adjusted to zero, but due to a clerical error, a statement was sent to the patient in error.”

UnitedHealthcare’s Landree said that “given the significant delay, we are addressing this issue directly with the physician’s office.”

“Mr. Kruzic will not be responsible for any additional costs related to this bill,” she said.

The Takeaway

麻豆女优 Health News’ “Bill of the Month” series receives complaints every year about ghost bills 鈥� bills that arrive long after a service is rendered.

Sometimes it’s because the insurer and hospital are haggling over payment, and the patient’s responsibility 鈥� usually a percentage of that number 鈥� can’t be calculated until the dispute is resolved. Other times, insurers audit old bills and, determining they overpaid, try to claw back the money, resulting in the patient (or even the patient’s surviving spouse) being billed for the difference.

For now, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.

An insurer’s word that a claim has been “processed” doesn’t mean that the insurer has agreed to pay and that the billing is resolved. It could also mean that the insurer balked at the bill or completely denied payment.

As for Kruzic and his affinity for hot peppers? He said he still loves spicy food, but in his cooking, “I will not use scorpion peppers again.”

Bill of the Month is a crowdsourced investigation by 麻豆女优 Health News and that dissects and explains medical bills.聽Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

This <a target="_blank" href="/health-care-costs/scorpion-peppers-spicy-food-colorado-bill-of-the-month-december-2025/">article</a&gt; first appeared on <a target="_blank" href="">麻豆女优 Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

An online search of his symptoms suggested he had a serious bacterial infection. Yoder drove the toddler from their home in the small town of Mechanicsburg, Ohio, to the Mercy Health hospital in nearby Urbana.

Staff in the emergency room there quickly confirmed that Darragh had scalded skin syndrome and said he needed to be taken by a private company’s ambulance to Dayton Children’s, a hospital about 40 miles away.

“I asked them: 鈥楥an I take him? Can I drive him?’” Yoder said. “And they were like, 鈥極h, absolutely not.’”

So, Yoder and her son got into the ambulance, with Darragh strapped in his car seat. The ambulance driver didn’t turn on the siren or drive particularly fast, Yoder said. The trip took about 40 minutes, she said. “It was fairly straightforward transportation from Point A to Point B.”

Yoder had heard that ambulance rides can be pricey. But she didn’t know how much her son’s ride would cost.

Darragh was hospitalized for three days and recovered from the illness.

Then the bill came.

The Medical Procedure

During the ride, the ambulance crew monitored Darragh’s vitals and an intravenous line, inserted at the hospital, carrying fluids and antibiotics, but he received no other medical treatment, Yoder said.

The Final Bill

$9,250, which included a “base rate” charge of $6,600 for a “specialty care transport” and a mileage fee of $2,340, calculated at $60 for each of the ride’s 39 miles. It also included $250 for use of an intravenous infusion pump and $60 for monitoring Darragh’s blood oxygen.

The Problem: No Insurance, Few Protections

The children’s hospital charged only about $3,000 more for the toddler’s three-day stay than the ambulance company charged for the ride, Yoder said.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid, the public health program that covers low-income residents, or for the Ohio Children’s Health Insurance Program, which covers moderate-income kids.

The Yoders belong to a Christian health care sharing ministry, with members paying into a fund that helps reimburse them for medical bills.

Unlike health insurance, such arrangements do not offer members negotiated rates with ambulance companies or other medical providers. And there are no state or federal billing protections that would help an uninsured patient in Ohio with a ground ambulance bill.

The federal No Surprises Act protects those with insurance from large bills for air ambulance transportation provided outside their insurers’ network agreements. But by the law 鈥� and even if they were, that wouldn’t have helped the Yoders, since they didn’t have insurance.

Patricia Kelmar, the senior director of health care campaigns , a national advocacy group, said ambulance charges vary widely. She said she’s seen per-mile charges ranging from less than $30 to more than $80, as well as base rates that differ dramatically.

Some patients, such as those with traumatic injuries, need ambulances with highly trained staff and advanced medical equipment, Kelmar said, so it makes sense that those rides would be more expensive. But patients rarely are told what the ride will cost until they receive a bill.

Jennifer Robinson, a spokesperson for Mercy Health, said she couldn’t comment on a specific patient’s case but said the staff follows established medical standards. “When a patient requires a higher level of treatment, ambulance transfer between facilities is best practice to ensure appropriate care,” she said in an email to 麻豆女优 Health News.

Kimberly Godden, a vice president for the ambulance company, Superior Ambulance Service, said a doctor at the first hospital requested a high-level transport for the patient, requiring specially trained staff.

“Our priority is always to ensure patients receive the highest-quality care when they need it most, and we respond to every call regardless of a patient’s ability to pay,” Godden said in an email. “Superior had the team and resources available to quickly and safely move the patient to the higher level of care they needed within the time frame set by the ordering physician.”

Godden said the company would offer a “charity care” rate to Yoder if the family qualified for it.

The Resolution

Yoder said she repeatedly discussed the bill with ambulance company representatives, including the option for charity care. They told Yoder the best deal they could offer was to reduce the total by about 40%, to $5,600, if the family paid it in a lump sum, she said.

After months of discussion, the family wound up agreeing to that deal, Yoder said. They put the charge on a new credit card, which gave them 17 months to pay it off with no interest.

They have agreed to payment plans with the two hospitals, which offered charity care discounts that dropped the bills to a total of about $6,800.

The Yoders expect the sharing ministry to reimburse them for about 75% of the payments they’re making to the hospitals and the ambulance service.

The Takeaway

Patients and their families should feel comfortable asking hospital staffers whether a recommended ambulance company is in their insurance network and how much the ride to another location will cost, said Kelmar, a national expert on such bills. “Shouldn’t the hospital know that?” she said. “I don’t think it’s that heavy of a lift.”

Kelmar said she doesn’t want to discourage people from taking an ambulance if a doctor says it’s necessary. Once consumers receive a bill for the service, she said, they often can negotiate the price down. It can help to look up what the ambulance service accepts as payment from government programs. Those rates are often much lower than the full-price charges patients see on a bill.

If the family had been covered by Ohio’s Medicaid program, the ambulance service would have been paid much less than it charged the Yoders. The public health program pays ambulance services for “specialty care transports,” plus $5.05 per mile. Those rates would have added up to $609.95 for the transportation part of Darragh’s ambulance ride.

Yoder said she wishes she had driven Darragh straight to the children’s hospital. If she had skipped the local ER, she said, they would have arrived at the bigger hospital sooner and she would have saved thousands of dollars.

But she didn’t feel as if she had a choice about putting her son in the ambulance, she said. The doctor told her it was necessary, and the hospital staff had already inserted an intravenous line. “I wasn’t going to pull out his IV line and just leave,” she said.

Yoder said she remains uninsured because she hasn’t seen any private insurance options that suit her family’s circumstances. No matter who pays the ambulance bill, she thinks the charges were much too high. She understands that patients can often negotiate discounts, she said, “but you shouldn’t have to work so hard for it.”

Bill of the Month is a crowdsourced investigation by  and  that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

This <a target="_blank" href="/health-care-costs/short-nonurgent-ambulance-ride-surprise-bill-of-the-month-november-2025/">article</a&gt; first appeared on <a target="_blank" href="">麻豆女优 Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Emmarie Huetteman 麻豆女优 Health News Emmarie Huetteman,聽senior editor, oversees a team of Washington reporters, as well as “Bill of the Month”聽and “What the Health? From 麻豆女优 Health News.” She previously spent more than a decade reporting on the federal government, most recently covering surprise medical bills, drug pricing reform, and other health policy debates in Washington and on the campaign trail.聽

The longest federal government shutdown in history is over, after a handful of House and Senate Democrats joined most Republicans in approving legislation that funds the government through January. Despite Democrats’ demands, the package did not include an extension of the expanded tax credits that help most Affordable Care Act enrollees afford their plans 鈥� meaning most people with ACA plans are slated to pay much more toward their premiums next year.

Also, new details are emerging about the Trump administration’s efforts to use the Medicaid program 鈥� for low-income and disabled people 鈥� to advance its immigration and trans health policy goals. And President Donald Trump has unveiled deals with two major pharmaceutical companies designed to increase access to weight loss drugs for some Americans.

This week’s panelists are Emmarie Huetteman of 麻豆女优 Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists

Anna Edney Bloomberg News

Shefali Luthra The 19th

Sandhya Raman CQ Roll Call

Among the takeaways from this week’s episode:

• Though the shutdown deal did not include an extension of the enhanced ACA subsidies, it came with a plan for a Senate vote by next month 鈥� on what exactly, it is unclear. Senate Republicans appear to be coalescing around providing money via health savings accounts rather than through the subsidies, while House Republicans seem more fragmented. The clock is ticking; the existing credits expire on Jan. 1, and open enrollment has begun.
• Even as the Trump administration is likely to be tied up in court over its efforts to use Medicaid to crack down on health care for immigrants and trans people, they’ve had a real chilling effect. Immigrants, for instance, are skipping medical care, and hospitals are cutting back on offering gender-affirming care for trans people for fear of losing federal funding.
• Trump’s newly announced GLP-1 price deals could help Medicare enrollees afford the weight loss drugs, potentially opening up access to a new population of patients 鈥� and customers. And a steady stream of policy reversals, unexplained dismissals, and negative news coverage is leading to worries that the FDA’s credibility is being undermined by internal drama. Also in question is whether it’s interfering with the agency’s work. Drug companies would likely say yes, and some within the FDA are trying to combat these concerns.
• A major anti-abortion group is leaning into the current electoral moment, targeting key states and preparing for sizable political contributions ahead of next year’s midterm elections. Abortion opponents see an opportunity to capitalize on voters’ changing motivations and reposition themselves to fit into the post-Trump Republican Party.

Also this week, 麻豆女优 Health News’ Julie Rovner interviews 麻豆女优 Health News’ Julie Appleby, who wrote the latest “Bill of the Month” feature, about a doctor who became the patient after a car accident sent her to the hospital 鈥� and $64,000 into debt. Do you have an outrageous medical bill? Tell us about it!

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Emmarie Huetteman: 麻豆女优 Health News’ “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance,” by Amanda Seitz.

Anna Edney: Bloomberg News’ “,” by Tim Loh, Hayley Warren, and Julia Janicki.

Shefali Luthra: The 19th’s “,” by Orion Rummler.

Sandhya Raman: BBC’s “,” by Nadine Yousif.

Also mentioned in this week’s episode:

• 麻豆女优’s “,” by Audrey Kearney, Alex Montero, Mardet Mulugeta, Ashley Kirzinger, and Liz Hamel.
• 麻豆女优 Health News’ “Trump’s HHS Orders State Medicaid Programs To Help Find Undocumented Immigrants,” by Phil Galewitz.
• NPR’s “,” by Selena Simmons-Duffin.
• Stat’s “,” by Lizzy Lawrence and Adam Feuerstein.
• Stat’s “,” by Lizzy Lawrence.

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From 麻豆女优 Health News” on , , , , , or wherever you listen to podcasts.

This <a target="_blank" href="/podcast/what-the-health-422-government-shutdown-aca-tax-credits-november-13-2025/">article</a&gt; first appeared on <a target="_blank" href="">麻豆女优 Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: 鈥榊ou have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, 鈥榊es.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital 鈥� which was not in-network with the insurance plan she got through her job 鈥� for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine 鈥� that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to 麻豆女优 Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the , which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for if the patient was not first formally admitted to a .

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital 鈥� and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also , which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to 麻豆女优 Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 鈥� about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient , agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done 鈥� coming to grips with what just happened.”

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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