No one is happy when their doctor tells them they need a colonoscopy. But the five-figure medical bill that later landed in Mike Meier’s mailbox turned out to be far worse than the procedure itself.
In December 2022, Meier’s doctor recommended a colonoscopy for routine cancer screening. When Meier arrived at Aurora Health Center in Greenfield for the procedure, he thought his Alliant Health Plans insurance would cover the cost.
After all, Meier’s insurance card, which he brought to the appointment, indicated that out-of-network care was covered. And his plan was proposed via HealthCare.govwhich he said covered preventative procedures.
Three months later, Meier received a bill for $10,745.
When Meier asked Aurora about the bill, the health system said Alliant denied the accusations because the procedure was performed by an out-of-network provider.
Through numerous complaints, calls and a letter to the insurance commissioner of their new home state of Georgia, Mike Meier discovered that Alliant had misprinted his insurance card: he had out-of-network coverage only for emergency care.
Despite the error, neither the health system nor the insurance company were willing to reduce Meier’s costs because the couple chose a plan with a $20,000 deductible. Because colonoscopy was not a covered service, that meant – misprint or not – they would still have to pay.
As users of Affordable Care Bills from HealthCare.gov For more than 10 years, the Meiers were shocked that a preventative procedure like a colonoscopy wasn’t covered.
“I had heard or thought at the time that it would be fully covered because it was an Affordable Care Act plan,” said his wife, Julie Meier.
After Mike Meier lost his job earlier this year, the couple told Aurora the huge medical bill could bankrupt them, she said.
In a statement to the Public Inquirer, an Aurora Health Care spokesperson acknowledged how “unexpected medical bills can be distressing” and advised patients to contact their insurer before a procedure.
“We are committed to being transparent in our billing practices and guiding patients as they navigate and plan the cost of their care,” spokesperson Adam Mesirow said.
He said Aurora offers several services such as cost of care estimates, financial assistance programs, and charity care.
Alliant Health Plans declined to comment, citing patient confidentiality. The company also refused to offer Mike Meier a patient privacy waiver that would allow Alliant to speak about his case.
The couple’s yearlong search for answers reveals how even the smallest guess can have major consequences on health care billing, despite reforms intended to avoid such surprises. This is particularly true for colonoscopies, which have been often confusing for patients and insurers navigate.
MORE: Two sisters discover the cost of a colonoscopy is painful
Alliant admits card was misprinted, but says it wouldn’t have made any difference
After receiving little information from Aurora and Alliant, the Meiers reported their case to the Georgia Insurance Commissioner last year.
In a letter to the commissioner, Alliant admitted that the insurance card “erroneously indicated that Mr. Meier received out-of-network benefits.” Alliant said Meier’s plan allows out-of-network coverage only for emergency medical services.
A corrected card was sent to Mike Meier 13 days after he received his colonoscopy, Alliant said.
Whatever the error, Alliant wrote, the colonoscopy would not have been covered.
Julie Meier did not understand why the preventive procedure, one of the most effective means of reduce the risk of colorectal cancer – would not be covered.
The answer is in the details.
All HealthCare.gov plans must cover certain preventive services, a Centers for Medicare and Medicaid Services spokesperson told the Public Inquirer. These services include colorectal cancer screening in asymptomatic adults aged 45 to 75 years and at average risk of colorectal cancer.
However, when Mike Meier underwent the procedure, he was only 44 years old, barely the age limit.
Additionally, the spokesperson said the procedure is only covered when performed by a provider in the plan’s network.
“However, nothing in the (Affordable Care Act) prevents the plan from covering out-of-network services,” a CMS spokesperson added. “This will be determined by the terms of the individual plan and applicable state law.”
Mike Meier had a benign polyp removed during screening, but CMS spokesperson confirmed that does not change a patient’s eligibility for the cover. Suppliers have patients incorrectly billed for polyp removal during colonoscopies in the past.
Wisconsin State Statute And administrative code also describe some additional protections.
In most cases, insurers covering Wisconsinites are required to cover colorectal cancer exams and laboratory tests for patients age 50 or older, or for patients under age 50 at high risk for cancer colorectal, according to the Wisconsin Insurance Commissioner.
Insurers are responsible for clearly indicating the maximum amounts to be paid
There was another guarantee that could have protected Mike Meier.
Under the Law without surprisesa law that took effect in 2022, group health plans and insurance companies are required to clearly state in writing the maximum out-of-pocket cap a patient can be charged.
The law aims to protect people from surprise billingthat is, when patients receive unexpected charges for medical care at an out-of-network facility, often after an accident or emergency.
In Mike Meier’s case, his Alliant insurance card should have accurately indicated the amount of coverage he had for out-of-network treatment, according to the CMS spokesperson. Additionally, Aurora could have verified the information before her appointment, although it was not required, the spokesperson said.
In Alliant’s response to the Georgia Insurance Commissioner’s investigation, the company said an Aurora Alliant representative was there at 4:04 p.m. on the day of Mike Meier’s appointment. That’s when Alliant confirmed it did not receive out-of-network benefits, the letter states.
At that point, the Meiers said, his procedure was already complete.
Lisa Grabert, a visiting research professor at Marquette University who specializes in insurance policies, said the unusual circumstances the Meiers faced with the inaccurate card could fit into a loophole of cases that the law doesn’t cover. not.
Since the No Surprises Act is a relatively new law for the U.S. healthcare system, Grabert said some companies are still adapting and many cases fall outside the scope of the law.
“(Lawmakers) need to go back and actually legislate to close possible loopholes in the law where people might try to get around the rules,” Grabert said. “I’m not sure the implementation of the law was exactly what anyone had anticipated.”
According to CMSIn the coming years, regulations will be issued to enforce provisions protecting patients who mistakenly receive care from out-of-network providers due to inaccurate information.
For now, insurance companies are expected to comply with these provisions using “a reasonable and good faith interpretation of the law.”
More: If You’re Having a Health Insurance Dispute in Wisconsin, Here’s How to Get Help
Days after the public investigator contacted Aurora, Meier’s bill was dismissed
After Mike Meier lost his job earlier this year, the couple, who were paying a $385 monthly medical bill, turned to a public investigator.
The public investigator contacted Aurora in late March. The next day, Julie Meier said Advocate Aurora’s vice president of patient experience, Bradley Krueger, called her husband to talk about the couple’s bill.
The following week, Mike Meier received a new statement stating that his charges had been reduced by $3,700.
Despite multiple attempts, the public investigator and the Meiers were unable to contact Krueger to find out how this discount was granted.
Regardless, Julie Meier said the reduction was a relief after nearly a year of attempts to challenge or reduce the fees.
“It’s definitely a step in the right direction,” she said.
Tamia Fowlkes is a public investigative reporter for the Milwaukee Journal Sentinel. Contact her at tfowlkes@gannett.com. Quinn Clark is a public investigative reporter for the Milwaukee Journal Sentinel. Contact her at qclark@gannett.com.
How to get help with an unexpected medical bill
If you receive a surprise medical bill, you can contact the federal government’s No Surprises Helpline at 1-800-985-3059 or submit file a complaint online at www.cms.gov/medical-bill-rights. The state or federal government may investigate the matter and be able to help.
The U.S. Department of Health and Human Services’ guide to Affordable Care Act and Medicare coverage requirements for colorectal cancer screening is available at health.gov.
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This article originally appeared in the Milwaukee Journal Sentinel: Couple faces $10,000 bill for colonoscopy after insurance card printing error
