Payson woman fights for coverage after health plan drops her provider, leaving her with $13K bill
by Matt Gephardt ksl, Sloan Schrage ksl · KSL.comKEY TAKEAWAYS
- Jennifer Rieske faced a $13,600 bill after her insurer dropped her hospital.
- Her insurer, Florida Blue, initially denied coverage despite prior authorization for the surgery.
- After the KSL Investigators reached out to her insurance company, Florida Blue approved billing as in-network under continuity of care.
PAYSON — Jennifer Rieske thought every T was crossed and every I was dotted before she went under the knife in April.
"I have this approval letter. I have all of these things," she said. "What happened?"
It's right there in that prior authorization letter from her insurance: "We have approved coverage."
With that written approval in hand, Rieske got the surgery. Then she got the hospital bill. She only expected to pay the $3,600 out-of-pocket deductible. But the bill surpassed $13,600.
"I paid it, and I felt so sick," she said. "I didn't sleep for several nights."
Rieske says the hospital told her she was billed as out-of-network. Now, wait a second – what about that prior authorization?
"I called the insurance, and she said, 'Oh, we dropped that facility,'" she said.
She says she learned her insurance dropped the hospital from their network on April 1, 15 days before her scheduled surgery. And just one day after they gave prior authorization.
But nobody told her.
Her appeal was denied, the insurer telling her the hospital is a "non-participating provider."
"I actually get emotional about it," Rieske said. "I'm sorry. I just feel like we've paid our premiums. We've been honest completely."
Out some $10,000, she decided it was time to call me.
Continuity of care
Can an insurance company really walk away from its own prior authorization?
Well, yes for several reasons: missing documentation, questions about medical necessity, policy exclusions – even clerical errors.
But as we began digging, our investigation took us into the legalese of federal code — specifically the relatively new No Surprises Act.
In it, we found a section on "continuity of care" that says when a medical provider is dropped by a health plan, some patients can keep the same level of care and the same co-pays, temporarily, for up to 90 days.
Not all patients qualify for continuity of care. You have to be undergoing treatment for a serious or complex condition, you're already an inpatient, or you're scheduled to undergo non-elective surgery, pregnant or being treated for a terminal illness.
Remember, Rieske's hospital was dropped just 15 days before her pre-authorized and scheduled surgery.
In-network
So, the KSL Investigators reached out to her insurance, Florida Blue, on her behalf to ask why she was being charged out-of-network rates.
A spokesperson wouldn't answer our questions, citing "privacy protections under federal law." But they insisted Florida Blue is "committed to ensuring ... members receive transparent, accurate billing and understand their coverage."
"It just felt very unfair to have this large bill that I wasn't expecting," Rieske said.
Well, after the KSL Investigators reached out to her insurance company, she did receive a letter from Florida Blue.
In it, she was told that "The Medical Director of your health plan has reviewed your request for continuation of treatment ..." and has now "approved" that her surgery will be billed as "in-network."
Continuity of care doesn't happen automatically; you have to apply for it. On the flip side, an insurance plan must notify you of the opportunity to continue care.
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The Key Takeaways for this article were generated with the assistance of large language models and reviewed by our editorial team. The article, itself, is solely human-written.