CHARLOTTE, N.C. -- Healthcare is something of a dirty word these days and medical bills can be costly – and complicated.
NBC Charlotte is helping one family who thought they had just a $50 co-pay and instead got a bill for more than $1,000.
Who’s to blame – and what can you learn to protect your own family?
Kristen Cole was convinced her husband had sleep apnea so she encouraged him to go to the doctor.
“What would really freak me out," she said. "He would stop breathing.”
Her husband Rob told us what happened when he went to the doctor's office.
“He said we need to do a sleep study to find out what’s going on," Rob said. "I asked the doctor do I need to get this pre-cleared told me the nurse would. The nurse came in and let me know it was authorized. She said it would be no more than the $50 co-pay.”
The doctor's office showed Cole a document they say proves the insurance company authorized the procedure. But when we showed the insurance company the document, a spokeswoman said they didn’t give an “authorization” number, they just assigned the case a number to initiate the process.
Rob Cole says his doctor at Charlotte Eye Ear Nose and Throat sent him to do the overnight study at a hotel near their office – the study confirmed he indeed had sleep apnea.
“And then in April, I got a letter from United my insurance company saying something wasn’t being covered and then in may I got a bill form Charlotte Eye, Ear Nose and throat for $1,185,” Rob added
“I was just outraged,” Kristen says.
"I was very angry very upset," Rob says.
His insurance company told him they’d deemed the sleep study medically unnecessary – and had never approved the study.
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“When I talked to the doctor office, they said the first thing they received from United was in March," Rob said.
The reason for the insurance company’s denial?
They say he should have done an in-home sleep study – that’s what was included in his coverage. Not the hotel, as he says his doctor suggested.
“They never mentioned an in-home sleep study?” we asked.
Rob responds, “Didn’t know that was possible.”
Rob says he also didn’t know his doctor's office was fighting with the insurance company about coverage.
“I didn’t know anything about it going on until I received the first bill about it and by then it was already in the appeals process.”
“How can the health insurance company determine whether a test is medically necessary when a doctor ordered it?" Kristen said. "They deny it if the doctor says you need it? There are so many people struggling with outrageous surprise medical bills.”
She’s right – we talked with UNCC professor Michael Thompson – who teaches a class on this.
“How tough is this for the average consumer to navigate?" We asked.
"Its tough," Thompson said. "I consider myself pretty savvy consumer and I've struggled trying to understand it and navigate it"
Thompson himself dealt with this on a personal level when his son was battling leukemia.
His best advice: Know your policy – most consumers have high deductible plans that require them to pay pretty hefty sums out of pocket.
Also, call your insurance company directly to make sure you understand what they will and will not cover – don’t rely solely on your doctor's office to handle that.
“It frustrates me, losing sleep...angry,” Rob says.
He says if he has to pay the unexpected bill from the doctor's office for getting his official sleep apnea diagnosis, he won’t be able to afford the treatment.
“Since they were the ones that told me it was only going to be $50, I don’t think I should have to pay $1,185,” Rob said.
He says he’s tried calling the office repeatedly since May and only got a call back when we started asking questions.
The doctor’s office refused to talk with us about his case saying only, “Our goal is to provide comprehensive, quality, and ethical health care in a favorable environment to all patients.”
Rob is now working with the office to appeal the decision with the insurance company. He is also filing an appeal with the state.
If you need to appeal a decision by your insurance company, you can find information on how to do that here:
https://ncdoi.com/Consumer/Requesting_Assistance.aspx