An Oklahoma woman got her hearing implant pre-approved by her insurer, but was left with a $139,000 medical bill

Caitlyn Mai, 27, has been dealing with single-sided deafness since high school, a condition caused by an infection that damaged one of her cranial nerves.

Mai, who lives near Oklahoma City, received a letter from her insurer last year stating that she was pre-approved for cochlear implant surgery. She checked to make sure her doctors and hospital were in the approved network and that she had met her deductible before going through with the surgery in December.

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The procedure was successful, but Mai was shocked when she received a bill for $139,362.74.

“I almost had a heart attack when I opened the account,” Mai told CBS News. “The stress and anxiety was tremendous.”

This is what happened

Mai began her investigation by calling the hospital’s billing department, but the representative didn’t know why her claim had been denied. When she called her insurer (HealthSmart, a provider of UnitedHealth Group), she was told that the hospital hadn’t itemized the charges correctly or included billing codes.

So Mai called the hospital back and told them how to correct the bill, giving her the name and fax number of the insurance representative. A hospital representative reportedly promised to fax the corrected, itemized bill within two to three weeks — but the weeks passed, and by late February, when Mai contacted her insurer, a representative said they still hadn’t received the bill.

Mai contacted the hospital again and decided to send the bill herself. But the following month, she received another payment reminder instead, offering a payment plan of $11,000 per month.

The story continues

A 2023 report from the accounting firm Crowe found that more than 30% of claims filed with commercial insurers early last year were not paid within 90 days. By comparison, only 12% of hospitalization claims and 11% of outpatient claims experienced the same delays with Medicare coverage.

According to the report, delayed payments can be caused by requests for information (RFIs) that halt the claims process. These can include a request for a signature, medical record or attachment for processing the claim. The RFI is largely the reason why the claim denial rate is 12 times higher among commercial payers compared to Medicare.

Unfortunately, data from the Kaiser Family Foundation shows that consumers rarely appeal when their insurance claim is denied. And when they do appeal, insurers often uphold their original decision.

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What should you do if your claim is rejected?

Mai has taken the appropriate steps to find out why the claim was denied. First, it is important to review your explanation of benefits and make sure that the service is covered by your insurance, that you meet the deductible, and that your medical care is in-network.

You can then contact your doctor and insurer to find out what is going on. Insurers are required to tell you why they denied your claim and to provide your claim file upon request. Like Mai, you can request the itemized bill with the billing codes so you can review it for errors.

If you still believe your claim should have been approved, you have the right to appeal. An internal appeal means that you can ask your insurance company to conduct a full and fair review of its decision.

You can also submit the decision to a third party for review. This external appeal means that the final decision is no longer in the hands of the insurer.

Luckily for Mai, her insurance eventually paid the claim, just over 90 days after her surgery, but it cost her peace of mind and time.

She estimates she spent at least 12 hours on the phone making sure the account was coded correctly and that the insurer had all the information to process the payment.

“It’s outrageous that the patients are ultimately making the decisions,” Elisabeth Ryden Benjamin, vice president of health initiatives at the Community Service Society of New York, told CBS News. “Bravo to Ms. Mai for having the energy to persevere and find a solution.”

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