Bill of the Month: $80,000 surprise could still happen under new law : Shots - Health News An insurer refused to pay bills related to the premature birth of the Bull family's twins because it said their delivery wasn't an emergency and their stays in the NICU weren't medically necessary.

An $80,000 surprise bill points to a loophole in a new law to protect patients

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A MARTINEZ, HOST:

A new law went into effect on January 1 called the No Surprises Act. It can protect people who need emergency care from owing huge medical bills. But what if there's a dispute about whether the care was an emergency? Already, we're seeing that loopholes remain. Dr. Elisabeth Rosenthal is editor-in-chief of our partner Kaiser Health News, and she's here to talk about this case and the new law. Doctor, welcome.

ELISABETH ROSENTHAL: Good to be here.

MARTINEZ: All right, so who are we meeting today for our February Bill of the Month?

ROSENTHAL: Today we're hearing from Sugar and Greg Bull, a young couple from Southern California. And they faced a bill over $80,000 after their twins were born.

MARTINEZ: Eighty thousand. All right, let's hear from reporter Stephanie O'Neill. She talked with mom Sugar. And let's listen to her report, and then we'll discuss it.

STEPHANIE O'NEILL, BYLINE: Sugar and Greg Bull of Huntington Beach, Calif., logged eight years of marriage before becoming parents in April of 2020.

SUGAR BULL: We always planned on having kids. We're both from really big families. I'm one of eight, and he's one of six.

O'NEILL: But due to health issues, Sugar says, they needed to work with a surrogate - in this case, technically known as a gestational carrier. Doctors implanted two of the couple's own biological embryos into the surrogate's womb.

BULL: The two strongest ones were a boy and a girl. So we chose to put two in because surrogacy's really expensive (laughter), and it's a lot less expensive to have two kids at once. And we wanted to have two.

O'NEILL: Sugar says she and Greg got to watch on an ultrasound screen as the doctor successfully implanted their babies-to-be. The pregnancy was smooth sailing up until 33 weeks. That's when the surrogate, who lived two states away in Utah, began experiencing high blood pressure and other symptoms of a serious pregnancy complication called preeclampsia.

BULL: And then at 34 weeks and two days, we were going to bed. It was midnight. And then she called us and was like, OK, it's happening, and the babies are coming tomorrow. So we got out of bed and got in the car and started driving through the night.

O'NEILL: And they arrived in Utah in time for the premature birth. The tiny twins needed oxygen and feeding tubes. Their son, Redford, required 11 days in the NICU; daughter Scarlett - 16 days.

BULL: They were healthy, but they weren't fully gestated, basically. So they needed to continue to grow and develop before they left or could survive on their own.

O'NEILL: But when it came time for their insurance carrier, Cigna, to pay for the twins' care, the company refused most of it, claiming in part that the babies' hospital stay wasn't medically necessary.

BULL: I was like, well, our babies couldn't survive on their own. They couldn't breathe. They couldn't eat. We couldn't have even taken them if we wanted to because the hospital said that they could not leave.

O'NEILL: For 15 months, Sugar exhausted herself trying to correct, to no avail, what she thought was a billing error of more than $80,000, all the while juggling a new life with twins and running her interior design company.

BULL: And I really don't have time to be calling the insurance and the hospital and going back and forth at all.

O'NEILL: Each call got her a different story. The hospital didn't submit the paperwork correctly or they didn't bill the treatment right. Sugar and Greg Bull appealed the issue with no resolution.

BULL: I just still felt like there's no way that we're paying this. And then they sent us to collections.

O'NEILL: To preserve their credit, the Bulls set up a payment plan and began searching other ways to get help for the bill that insurance should have covered.

For NPR News, I'm Stephanie O'Neill.

MARTINEZ: OK, Dr. Elisabeth Rosenthal is back here to help us understand. Now, the Bulls had a special circumstance with their twins. They were born via surrogate in another state. How had they prepared for that?

ROSENTHAL: Well, they knew the babies would be born at an out-of-network hospital, and they were expecting to be billed their family out-of-pocket maximum. That's about $10,000. But, of course, what they got was much more.

MARTINEZ: Yeah. Instead, they got bills for more than 80,000. So what explanations did they get from the hospital and the insurer, and what ultimately happened with their bill?

ROSENTHAL: Well, the insurer blamed the hospital for not providing enough information to show that the births were an emergency and the NICU stay, and the hospital says it did nothing wrong. The Bulls eventually started working with a third-party investigator, and they ultimately paid that company $8,000 to settle the bill instead of setting up a kind of long-term payment plan on a bill that they never should have owed.

MARTINEZ: Now, this all happened in 2020 before the No Surprises Act was in effect. How does this relate to the new law? Would it have spared them all this red tape?

ROSENTHAL: Well, that's why we wanted to bring you this story. The law does offer significant protections, and that's great, but there are still caveats. If a hospital or an insurer says this wasn't an emergency, the law doesn't necessarily apply. It's a loophole people need to watch out for. And we expect we're going to hear others, too.

MARTINEZ: So what can patients do?

ROSENTHAL: Well, you still need to be on guard. You might have to do the legwork and provide the documentation that the care was, in fact, an emergency. It's not about your perception. What matters is what's written in the chart. So make sure you ask your doctors to use that word emergency and provide the evidence.

MARTINEZ: All right, that's good advice. Dr. Elisabeth Rosenthal of Kaiser Health News, thanks a lot for being here.

ROSENTHAL: Thank you for having me, and we'll be watching for other loopholes in the law this year.

MARTINEZ: Absolutely. Now, if you have a confusing or outrageous medical bill, please go to NPR's Shots blog and tell us all about it.

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