116 3rd St SE
Cedar Rapids, Iowa 52401
Back in October, Bryce Williams dislocated his collar bone while playing in an intramural football league. The injury was severe - the bone was pressing on his windpipe and carotid artery, blood vessels in the neck that deliver blood flow to the brain.
Doctors at UnityPoint Health-St. Luke's Hospital in Cedar Rapids, realizing the seriousness of the injury, sent him to the University of Iowa Hospitals and Clinics in Iowa City, where he had surgery and was hospitalized for a day.
Williams, 18, is now recovering at his Cedar Rapids home, said his mother, Tracy Ehlert. His arm is in a sling and he's wearing a brace.
However, that relief was short-lived.
A few days after he was released from the hospital, the family received a letter from Amerigroup - one of the three private insurers that manages the state's Medicaid program - saying Williams's inpatient services had not been not approved.
The cost of his services - an ambulance ride, CT scan, surgery and overnight stay - were more than $26,000, Ehlert said.
'You had a collar bone dislocation,” the Amerigroup letter read. 'You were treated overnight. Your pain was controlled. Your arm and neck were OK. You needed to be treated at the hospital. You did not need acute inpatient level of care.”
Amerigroup then pointed to a piece of Iowa Code that details criteria needed for approval of inpatient hospital services.
But Ehlert said the family never ran into these issues under the state-run program, adding Williams is her 'accident-prone” child who winds up in the emergency room at least once a year.
The state handed over its nearly $5 billion Medicaid program with almost 600,000 enrollees to three private insurers - Amerigroup Iowa, AmeriHealth Caritas Iowa and UnitedHealthcare of the River Valley - on April 1.
The family is appealing the decision, a process that may not yield any new results. The appeal is reviewed by an Amerigroup employee who did not make the original decision and does not report to the person who made the original decision.
Amerigroup was not able to comment on the specific case and was unable to provide The Gazette with the percentage of appeals that are overturned versus the number that remain intact.
Ehlert, though, is left wondering why the insurance decision has come to a different conclusion than the doctors at UIHC. She received the physician's notes, which she included in the appeal.
'The letter recommended seeking legal help, which is concerning,” she said, adding if the family is forced to pay the hospital bill, it would 'break them.”
However, UIHC said typically it would not bill the patient if he or she has active Medicaid coverage and the payer denies an inpatient bill for medically necessary services.
If an MCO denies an inpatient claim, UIHC's Patient Financial Services staff generally will investigate to determine the cause for the denial, the hospital said.
If financial services find a claim error, the error will be corrected and resubmitted to the payer with all necessary documentation. If the payer denies in error, financial services will appeal and continue to follow up until appropriate reimbursement is received.