Ellen Gentile was lying on the operating table in a hospital gown with an IV in her arm when her family said they learned the neck surgery she thought was approved might not be covered at all.
The Millburn, N.J., mother has been living with excruciating pain from a ruptured disc, which left her partially paralyzed and unable to move her arms or hands. Expecting long-awaited relief, she arrived at the hospital ready for surgery after being told to come in the night before.
“They called me the night before and told me, come on in,” Allen told ABC 7 on your side Consumer reporter Nina Pineda (1). “You know, we thought everything was approved.”
As her condition worsened and she became unable to move, the surgery was eventually performed. But when the bills were tallied, Gentile and her husband, Matthew, faced about $126,000 in medical bills.
However, Allen’s experience is not uncommon. A 2024 Commonwealth Fund study found that nearly half of insured Americans face unexpected medical bills (2). Here’s how the situation develops and what patients can do if coverage fails.
When Pineda later sat down with the couple to track down where the glitch might have occurred, she asked if anyone had warned them that the surgery might not be covered.
“Well, the operations director said that would usually be taken care of,” Matthew recalls.
The couple submitted claims totaling six figures, including about $37,000 for an artificial spinal device and about $9,000 for anesthesia, but after submitting their claims, their claims were denied. They subsequently appealed the decision twice, but both attempts were unsuccessful.
when 7 on your side After later contacting her insurance company, Independent Blue Cross, and providing Dr. Gentile’s certification of medical necessity, the insurance company maintained its position on the grounds that the device was not FDA-approved and the procedure was not officially authorized. Still, the exchange revealed one remaining option: the couple could go through an independent third party for a final review.
For many Americans, dealing with medical billing and insurance disputes can be overwhelming. According to data from the Kaiser Family Foundation, approximately 44% of U.S. adults say it is difficult or somewhat difficult to afford health care (3). Financial stress is especially pronounced for those without insurance, with about 82% of uninsured adults under 65 reporting difficulty paying for care, compared with about 42% of those with health insurance.
Allen’s experience reflects a broader reality: Denying coverage can affect patients of all income levels, even those who understand the health care system. In a separate case previously covered money wise In November, physician Nicole Hughes, director of the Farley Center for Health Policy at the University of Colorado, initially faced nearly $64,000 in hospital bills after undergoing surgery for a broken ankle.
Her insurance company agreed that the procedure itself was medically necessary, but refused to cover her overnight hospital stay, explaining that the services had been billed together as part of a bundled claim. Technical differences ultimately determine what insurance companies are willing to pay. Hughes later told money wise Patients are rarely able to think strategically about insurance approval or network status in the aftermath of trauma.
“Even as a physician who works in health policy, it never occurred to me to inquire about my level of care and/or call my insurance company,” Hughes said.
Although the details of the two cases differed, they had one thing in common: Neither patient accepted their initial denial. Disputing a coverage decision can have repercussions, but many Americans never take this step. The Commonwealth Fund found that 45% of insured adults reported receiving a bill for care they believed should be covered, while nearly one in five said they were not covered for services recommended by their physician (4).
Even so, less than half of those who experienced billing errors or denials formally challenged them, often because they were unaware of their right to appeal.
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Finally, Ellen expressed her gratitude 7 on your side Help families make final review selections.
“I mean, you were able to provide us with a more advantageous path and it was approved,” Matthew said.
An independent third-party review overturned the denial, and the bill of $126,680.25 was paid. Still, unexpected medical bills can happen to almost anyone. Sara Collins, senior scholar and vice president for health care coverage and access at The Commonwealth Fund, told CBS MoneyWatch that confusion about the billing process often leaves patients unsure of what to do (5).
“Many people with insurance are facing unexpected bills and being denied doctor-recommended care,” she said. “A lot of people don’t know what to do — people are confused about the health care process itself, whether it’s how it’s billed or who’s responsible.”
In Hughes’ experience, she said it’s important to document everything and ask the right questions when faced with denial.
Requiring a written explanation for a denial can also help clarify whether the issue is related to prior authorization, medical necessity standards, network status, or billing codes. Patients can work with the provider’s billing office to resubmit the claim with updated documentation or corrected coding.
If the problem persists, consumers can file a formal appeal with the insurance company or request an outside review through their state’s insurance department, an important step that proved decisive in Allen’s case.
Even if you end up in denial, there may still be options. Some hospitals offer financial assistance programs, often called “charity care(6).” The IRS defines charity care as free or discounted medical services provided to people who meet an organization’s eligibility criteria but are unable to pay all or part of the cost of treatment.
State insurance departments and patient advocacy groups can also provide guidance to help patients better understand their rights and resolve complex billing disputes. Allen’s experience reminds us that an insurance company’s first answer is not always the final answer.
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ABC 7 (1); Commonwealth Fund (2, 4); Kaiser Family Foundation (3); CBS News (5); Internal Revenue Service (6)
This article provides information only and should not be considered advice. It is provided without any warranty of any kind.
