- A West Valley City woman faced a $5,000 bill due to medical code issues.
- Lori Brown's insurance denied reimbursement for out-of-network surgery at Holy Cross Hospital.
- The hospital refunded her and agreed to bill her insurance directly.
WEST VALLEY CITY — A West Valley City woman says trouble over medical codes is stopping a hospital and her insurance from getting on the same page. Now, she faces having to pay over $5,000 out of pocket for a procedure she says should be covered.
As a middle school teacher, Lori Brown needs her voice. But around Christmas time last year, it began to fail.
"I could hardly talk," Brown said. "It was that bad."
Out-of-network
Doctors told her she'd need surgery at CommonSpirit Holy Cross Hospital — Salt Lake, but it's out of her insurance network.
"They were the only hospital with the right laser equipment to do the procedure," she explained.
Brown braced herself for a higher co-pay and deductible. And she said the hospital told her she'd have to pay upfront, but her medical insurance provider's out-of-network benefit would reimburse her a portion of that money.
So, she paid nearly $5,200 and got her voice back. However, her insurance now won't reimburse anything. She said they're telling her that the hospital's itemization is not sufficient due to medical codes.
"Missing diagnosis codes, missing procedure codes," Brown read from the denial letter.
Now, there are medical codes in the documentation the hospital gave to Brown, but they're not in an industry standard that her insurance recognizes. She said that despite all her calls, she can't get the hospital to send her a new itemization with acceptable coding.
"It's like, why?" she said. "That's ridiculous."
So, her next call was to Get Gephardt.
Code resolution
The KSL Investigators contacted the hospital's owner, CommonSpirit. We asked why she cannot get an itemization using codes her insurance will accept.
A spokesperson told KSL that because Brown paid up front, the hospital didn't generate its regular claim form that an insurance company would use. They apologized for the misunderstanding and said they would refund her what she had paid and then bill her insurance directly for the treatment.
The spokesperson also insists the process was started weeks earlier, before Brown called Get Gephardt.
That was news to her. She said she wasn't told about the refund or the new insurance billing until after Get Gephardt got involved. Either way, she now has her money back.
"It just seems so simple," Brown said.
Federal law says people have a right to copies of their medical and billing records held by a provider or insurance company. Those will include procedure and diagnosis codes.
If denied or delayed, people can file a complaint with the Utah Department of Insurance or the Division of Consumer Protection.
