The migraine tormenting the 32-year-old in April was even worse than usual. After a week of piercing head pain, she went to an urgent care center near her home in Champaign, Illinois, and received an , a non-steroidal anti-inflammatory drug that usually helps with her symptoms. The doctor at the clinic told her that if the pain didn’t improve, she should go to an emergency room the next day.

It didn’t improve. So the next morning, Daniels’ sister took her to a nearby ER, at Carle Foundation Hospital in Urbana. She said the ER didn’t seem very busy when she registered at the front desk and was taken briefly to an exam room, where a staffer checked her vital signs and asked whether she had migraines frequently. Then they told her to sit in the waiting room until she was called.

She and her sister waited. And waited. By then, Daniels said, she was vomiting every 10 minutes, a during one of her serious migraine attacks.

After four hours, with no indication that Daniels would be seen anytime soon, her sister took her to another hospital. There, after a wait of about an hour and a half, Daniels was seen and received treatment, including more Toradol and anti-nausea medication.

Having left Carle without getting treatment, Daniels didn’t expect to be charged.

Then the bill came.

The Medical Service

Daniels said a staffer checked her pulse, temperature, and blood pressure when she arrived at Carle. She said she received no other services, nor was she seen by a doctor.

At one point while they sat in the waiting room, Daniels said, her sister asked for an ice pack for her head, but the staff wouldn’t provide one.

“ER triage is driven by risk of death or serious harm, not by level of suffering,” said Jennifer Robblee, a neurologist at the Barrow Neurological Institute in Phoenix and a board member at the Association of Migraine Disorders. “Migraine patients without red flags are unlikely to be prioritized, as they are not at immediate risk of dying.”

The Bill

$410 for an “Emergency Room Level 1” visit. Daniels said she requested an itemized bill showing how the hospital arrived at that figure but never received one.

This is not the first time that a patient has complained to 51ÊÓƵ Health News’ “Bill of the Month” about receiving a bill after leaving a Carle Health emergency room without being treated. In 2023, Maggi Wettstein took her toddler to a different Carle Health hospital and was billed $445 for a nasal swab test for covid and influenza. They, too, left before getting treatment.

The Billing Problem: What Counts as Care?

Though Daniels left the emergency room after a four-hour wait without being treated, the hospital billed her anyway. Her health plan, provided through her job as a state employee, paid for her treatment at the second hospital but denied the Carle claim, leaving her on the hook for the charges.

“Under the terms of her health plan, claims associated with a patient leaving the facility against medical advice are not eligible for coverage,” Leslie Porras, a spokesperson for HealthLink, which administers Daniels’ plan, said in a statement.

When Daniels asked about her bill, a Carle representative responded in an email that said: “Effective March 1, 2026, Emergency Department visits may result in charges even if you are not seen directly by a provider. When you arrive at the Emergency Department, your visit begins as soon as care is initiated.”

The email said “care” could mean registration and nursing assessment, in addition to diagnostic testing and treatment. It said that even if patients leave without being seen by a provider, they may still be charged, because the hospital is using resources to maintain its staff, space, and equipment.

Carle Health declined to discuss Daniels’ bill or her care with 51ÊÓƵ Health News, even though Daniels signed a privacy waiver that authorized it to do so.

In a statement, Carle Health spokesperson Brittany Simon said, “Our Emergency Department has consistent billing practices for triage care,” referring to the process through which patients are evaluated to ensure the most critical cases are treated first.

“Carle Health takes patient concerns seriously and supports transparency in our billing processes,” she said.

Typically, an ER bill would include separate dollar amounts for physician charges and hospital charges, said Amber Padron, assistant director of case management at the Patient Advocate Foundation, a nonprofit that assists patients with chronic or life-threatening conditions.

Daniels’ bill listed a single charge, for $410. Under the description, it said “Emergency Room Level 1” and included the current procedural terminology code “99281.” CPT codes are used to bill for evaluation and management, or E/M, services provided by a medical professional. is the lowest level of emergency care.

But there’s a catch: According to the American Medical Association’s CPT guide, “Triage alone is not an E/M service; therefore, it cannot be reported with an E/M code.”

It gets murkier. According to Robert Mills, a spokesperson for the AMA, the physician charge for an emergency visit under that CPT code would generally be significantly less than $410.

“It is likely the hospital consolidated the provider-billed charge with a facility fee,” Mills said, referring to a fee that hospitals tack onto bills to cover their overhead costs, such as utilities.

Amid the billing uncertainty, Daniels is clear about one thing: The decision to charge ER patients who leave without getting treatment is recent.

In 2025, she went to the same emergency room with gastrointestinal problems. After waiting for several hours, she went elsewhere for care. She said that before leaving, her mother, who accompanied her that day, confirmed with the front desk that Daniels wouldn’t be charged if they left then. And she wasn’t.

“So when I went in for this visit in April, I had no idea I was going to be charged, because it was a very similar set of circumstances,” Daniels said.

The health system didn’t respond to a question about why it changed its policy.

The Resolution

Carle didn’t budge. According to the health system’s email to Daniels, “the charges have been determined to be accurate and fully supported by the medical record documentation.”

Daniels said she paid $25 of the $410 bill and has applied for financial assistance.

Meanwhile, according to HealthLink’s statement to 51ÊÓƵ Health News, Daniels can contest her health plan’s denial: “Ms. Daniels has the right to appeal the decision through the established appeals process.”

She’s considering it, but she remains outraged about what happened.

“How is it ethical or even legal for a hospital to essentially bill for occupying a waiting room?” she asked.

The Takeaway

Don’t assume you won’t be billed if you leave a hospital before receiving medical care. You can check with the front desk about the facility’s policy, as well as ask your insurer whether it provides coverage for such bills.

If the hospital billing department isn’t giving you information about what services you’re being billed for, request your medical records, said Padron, of the Patient Advocate Foundation.

Furthermore, when your health plan processes a claim, you should receive an explanation of benefits informing you of that and explaining what you may owe. Keep an eye on your mail and your insurance portal.

When a claim is denied, filing an appeal with your health plan is always a smart idea, Padron said.

“It’s always going to be a no if you don’t appeal,” she said.

Bill of the Month is a crowdsourced investigation by 51ÊÓƵ 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .

“The national security might be something worth paying for,” Sen. Bill Cassidy of Louisiana, chairman of the Senate Health, Education, Labor, and Pensions Committee, said July 22 in an exclusive interview with 51ÊÓƵ Health News.

The U.S., which has grappled with drug shortages in recent years, relies primarily on China to produce the active ingredients in many antibiotics, according to in JAMA Health Forum. Domestic facilities have closed or shifted to producing other drugs.

“Do we want China to have that sort of leverage for these drugs to be produced principally, maybe 99%, over there, and we don’t have access to them if tension rises between the two countries?” said Cassidy, who is a physician.

On July 21, Trump said in a that he would give generic drug companies two years to move production back to the U.S., after which he would impose 100% tariffs on imported products, rising to 200% the following year. Generic drugs make up an estimated 90% of all prescriptions filled in the U.S.

Cassidy, who has served in Congress , lost his bid for reelection in May after Trump endorsed a Republican primary challenger, Rep. Julia Letlow.

Last month, more than 16 months after his vote to confirm Robert F. Kennedy Jr. as head of the Department of Health and Human Services, on CBS News’ Face the Nation that the secretary broke promises he made to the senator, including that he would not change the federal recommendations for childhood vaccines.

Asked whether he would summon Kennedy again to discuss those promises, Cassidy said he had asked for him to appear before his committee but had not heard back about whether he would do so. Kennedy in April to discuss the Trump administration’s fiscal 2027 budget request for HHS.

Cassidy told 51ÊÓƵ Health News that when he agreed to vote to advance Kennedy’s nomination, he trusted that Kennedy would keep his word about not disparaging vaccines.

“If they agree to guardrails and disregard those guardrails, you can judge me,” Cassidy said. “You may decide my judgment wasn’t very good, but I don’t think you can say I acted in bad faith.”

Regardless, Cassidy added, Kennedy was going to exert influence in the administration, and he thought it would be better for Kennedy to be in an official post, where his work would be subject to oversight.

“I’m pretty sure that RFK was going to have the president’s ear whether he was in office or not,” he said.

While Kennedy’s efforts to roll back federal vaccine recommendations are being blocked by courts, this week reported that the number of measles cases confirmed in the U.S. so far in 2026 has exceeded the total for 2025 — making it the highest number of cases in 35 years.

Cassidy, a principal author of the 2020 No Surprises Act targeting surprise medical bills, also said he doesn’t think Congress needs to make modifications to the law in the wake of reports that doctors and other healthcare providers are winning huge payouts under the arbitration system the law created. The No Surprises Act was intended to shield patients from receiving big bills for receiving medical care they didn’t know was outside their health plan’s network.

An analysis by this week found that providers were awarded nearly $15 billion in disputed claims in 2025, more than triple the 2024 figure of $4.08 billion.

“The initial step to make sure that people are getting their best deal is price transparency,” Cassidy said.

The HELP Committee on July 22 overwhelmingly approved advancing the Patients Deserve Price Tags Act, a bipartisan bill that would further expand the requirements that hospitals, insurers, and other healthcare providers make prices public and available to patients and employers. A House committee advanced a similar bill this week, also with bipartisan support, but it remains unclear whether either measure will be approved by the full House and Senate.

The interview — in which Cassidy also discussed his — was part of the “How Would You Fix It?” series featuring Julie Rovner, 51ÊÓƵ Health News’ chief Washington correspondent and host of the What the Health? podcast.

An abbreviated version of this interview aired July 23 in Episode 456 of What the Health? From 51ÊÓƵ Health News: “A Shrinking Safety Net.”

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

So he didn’t know he had a bill to pay. After he and Tix returned home to Minnesota in April, they got a letter from Wellcare, the insurer that provided his drug plan, saying his coverage had been terminated after three months of unpaid premiums totaling $28.80. Under Medicare’s rules, he can’t enroll in a plan again until the fall, for coverage beginning in 2027.

Pare takes Xarelto, a blood thinner that reduces his risk of strokes, blood clots, and pulmonary embolism. “He could bleed to death without it,” Tix said. A 90-day supply of the drug costs about $1,800 using a coupon from GoodRx, a discount drug website, she said.

Pare is among tens of thousands of Medicare beneficiaries who were on Wellcare’s Value Script drug plan who will likely go without prescription drug coverage for the rest of the year because they didn’t pay premiums for three months.

Next year, thousands more people in 32 states and Washington, D.C., who are enrolled in zero-premium drug plans from Wellcare and other insurance companies may find themselves in the same situation if their premiums go up and they don’t realize it, according to a 51ÊÓƵ Health News analysis of drug plan data. Premiums and other changes for 2027 will be unveiled in September.

Going without medication can be life-threatening, especially for Medicare beneficiaries. take one or more prescription drugs, according to the Centers for Disease Control and Prevention. Almost half live with four or more chronic health conditions that can cause functional or cognitive impairments.

Congress added prescription drug coverage to Medicare in 2003. But the coverage is administered by commercial insurance companies, which compete fiercely with one another for the business of about enrolled in drug plans.

Zero-dollar or very low monthly premiums have helped make Wellcare’s Value Script the bestselling stand-alone prescription drug plan in Medicare, with nearly 6 million customers across the U.S., according to government data. But in 26 states and Washington, D.C., some Value Script members who didn’t have to pay a premium last year were caught off guard by increases in 2026.

After a two-month grace period — which Wellcare extended to three — Medicare drug plans can drop customers who don’t pay their premiums, no matter how small the amount. Some members who lost their coverage in Nevada, for example, owed as little as $8.10 for three months, according to a 51ÊÓƵ Health News analysis of Medicare drug plan data.

Wellcare terminated coverage for about 140,000 Value Script beneficiaries in April, according to a person with knowledge of the matter who was not authorized to speak publicly about it and feared reprisals at work for doing so. About 40,000 of the people who were dropped may be able to enroll in new coverage immediately because they have low incomes and receive financial assistance through a program Medicare calls “.”

Multiple state officials said they had heard the same disenrollment figures, including Nevada’s insurance commissioner, Ned Gaines, who chairs the National Association of Insurance Commissioners’ senior issues task force; Rebecca Gouty, director of the State Health Insurance Assistance Program in West Virginia; and Tim Smolen, director of Washington state’s Statewide Health Insurance Benefits Advisors. The West Virginia and Washington initiatives are part of the federally funded , or SHIP, which provides free, unbiased help navigating Medicare.

Surprise Bills

The Centers for Medicare & Medicaid Services, which oversees Medicare drug plans, declined to provide the number of Value Script members who lost coverage due to unpaid premiums. “The agency does not publicly provide plan-specific disenrollment figures or state-level breakdowns related to the non-payment of premiums,” Christopher Krepich, a spokesperson, said in a written statement to 51ÊÓƵ Health News.

Centene Corp., Wellcare’s parent company, also declined to provide disenrollment numbers.

“We recognize how disruptive a loss of coverage can be and are committed to helping members understand their options,” said Sarah Baiocchi, senior vice president for specialty and prescription drug plans at Centene. She acknowledged that “some members in our Value Script plan experienced a premium for the first time, or for the first time in several years.”

Baiocchi said all Value Script members received a CMS-required annual notice of changes in September, before the premium increases took effect.

A sent to members in two states and Washington, D.C., is 21 pages long. The new premium is mentioned on pages 3 and 8, along with changes to out-of-pocket costs and how to find updates on covered drugs and network pharmacies.

The company also informed members about 2026 premium changes through phone calls, text messages, regular mail, or email, Baiocchi said.

People who are dropped are not able to reenroll or join another drug plan until the start of the open enrollment period this fall for coverage beginning Jan. 1, unless they qualify for an exception, Krepich said. And because they will have gone without coverage for at least 63 days, they could be hit with a permanent that increases every year for the rest of their lives.

“Medicare should be doing something about this so that we can go ahead and get coverage now,” said Wayne Bennett, 74, who lives in Durham, North Carolina.

In May, he found out that Wellcare had canceled his Value Script plan because he hadn’t paid his $3.60 monthly premiums. He takes nine prescription drugs to treat his blood pressure, glaucoma, chronic obstructive pulmonary disease, and other health problems. He filled most of his prescriptions — including several at no cost — before he lost coverage. He doesn’t know what he’ll have to pay when his supply runs out.

Gouty, the West Virginia program head, said many Medicare beneficiaries arrange for their monthly drug plan premium to be automatically deducted from their Social Security benefits, and that many likely thought that choice remained in place until they changed it.

“They didn’t realize that when the plan was a zero premium in 2025, that stopped the Social Security premium deduction and they would have had to reelect it for 2026,” Gouty said.

In other words, even if they mistakenly thought the premium was still zero, Medicare beneficiaries would have needed to somehow allow Social Security to make deductions — something the agency doesn’t do — or set up a payment plan through their bank or credit card in case payment was necessary.

“That sounds goofy,” Tix said.

Centene’s Baiocchi blamed the Social Security Administration for the problem: “We believe this was a key driver of non-payment disenrollments and subsequent complaints.”

Spokespeople for the agency referred questions about the matter to CMS.

Krepich said legal requirements for drug plan enrollment and disenrollment limit what CMS can do to help beneficiaries who lose coverage for not paying their premiums.

‘Pretty Upset’

Now that Pare has no prescription drug coverage, his doctor replaced his blood thinner medication with a much less expensive drug that should be just as effective. Pare paid $111 for four other medications that used to be free under his Value Script plan. He hasn’t had to refill four more prescriptions yet and doesn’t know what they will cost, Tix said.

If Wellcare members knew about the premium increases, they could have set up direct billing or an automatic payment plan early this year before the payment grace period ended April 1. But they would have been able to fill prescriptions during the grace period, so if they didn’t see Wellcare’s notices, they likely assumed there was no problem with their coverage.

Bennett, the North Carolina man, said Wellcare used to send him text messages with health tips and reminders when it was time to pick up a prescription. He didn’t know his premium had increased from $0 to $3.60 until it was too late.

“I was pretty upset,” he said, when he called the company. “The premium wasn’t that much, and I was ready to pay it right off the bat. I had my credit card out ready to make the payment.”

The customer service representative wouldn’t let him pay because his coverage had been canceled, Bennett said.

Hoping to restore it, Bennett called , a Durham nonprofit that advises Medicare beneficiaries and is one of more than 2,200 SHIP sites across the country. He was told he must wait until January to restart his drug coverage, said the group’s executive director, Gina Upchurch.

He doesn’t qualify for the “Extra Help” low-income subsidy or meet other CMS criteria for a , which would allow him to change drug plans during the year. CMS typically allows midyear switches for beneficiaries who, for example, move out of their plan’s service area, experience a natural disaster, or get help paying for drugs from a .

Senior PharmAssist was able to help one of its participants join another drug plan after she lost Value Script coverage because she is in North Carolina’s pharmacy assistance program for people with HIV/AIDS and has limited income, Upchurch said.

A further exception allows any Medicare beneficiary to enroll at any time in a drug plan that has earned five stars, the top grade in Medicare’s performance ratings. However, there are no five-star Medicare drug plans available to the general public. Only two insurers offer five-star plans, and only for retirees from certain employers. Their combined enrollment is about 8,700 as of June 1, according to the insurers.

But Upchurch, with more than two decades of Medicare expertise, doesn’t blame beneficiaries for not paying attention or for assuming Wellcare’s messages were bogus. Older adults are particularly vulnerable to identity theft and other scams and are often advised to ignore junk mail and calls from telemarketers.

Since Value Script members such as Bennett continued to get their prescriptions filled during the payment grace period, “why wouldn’t they think this was a scam?” Upchurch asked. “They are constantly bombarded by people selling them something that’s illegitimate or trying to scam them.”

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

“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 51ÊÓƵ 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 51ÊÓƵ 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .

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 — 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: ‘You 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 — 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 — another subsidiary of the same parent company, UnitedHealth Group — 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 ‘Tug-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 — 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 — which he originally expected to last a year — 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’ 51ÊÓƵries, 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 — 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 51ÊÓƵ 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .

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 51ÊÓƵ 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 51ÊÓƵ 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 51ÊÓƵ, a health information nonprofit that includes 51ÊÓƵ 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 — 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 51ÊÓƵ Health NewÌý²¹²Ô»åÌý 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .

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 51ÊÓƵ 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 51ÊÓƵ 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.

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

Treatment for a Florida Medicaid enrollee’s heart attack cost nearly $78,000 — about as much as surgery for an uninsured Montana woman’s broken arm.

In 2025, these patients were among the hundreds who asked 51ÊÓƵ Health News to investigate their medical bills as part of its “Bill of the Month” 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 — if push comes to shove — fight their own medical bills. Here are our 10 takeaways from 2025.

1. Most insurance coverage doesn’t start immediately. Many new plans come with waiting periods, 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 cancer screenings. Call your insurer — or, for job-based insurance, your human resources department or retiree benefits office — 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 may be limited to certain doctors, services, and dates.

4. Get a cost estimate in writing for nonemergency procedures. If you object to the price, negotiate before undergoing care. 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 connected to a health system, 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 determined to be “medically necessary.” And while there may be no choice about taking an ambulance, if a transfer to another facility 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 self-pay or charity care discount.

8. There’s help available for Medicaid patients. If you get a bill you don’t think you should owe, 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 an open line of communication with insurance companies, local hospitals, and other major providers — and advocating for you is their job.

10. When all else fails … you can write to “Bill of the Month”!

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 — 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 — 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 — 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 — 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 ‘Crippling’ 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 51ÊÓƵ 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .

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 — 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 — 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 51ÊÓƵ 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, ‘By 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 51ÊÓƵ 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

51ÊÓƵ Health News’ “Bill of the Month” series receives complaints every year about ghost bills — 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 — usually a percentage of that number — 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 51ÊÓƵ 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .

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: ‘Can I take him? Can I drive him?’” Yoder said. “And they were like, ‘Oh, 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 ground ambulance services aren’t covered by the law — 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 51ÊÓƵ 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 51ÊÓƵ 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 article first appeared on 51ÊÓƵ Health News and is republished here under a .