For the most part, Keyanna Jones and her husband thought they knew what to expect when their daughter Chloë had eye surgery last fall.
Even Chloë, who was in kindergarten, had a good understanding of how things would go that day. Before the procedure, a hospital worker gave her a coloring book that explained the steps of the surgery — a procedure to correct a condition that could have eventually interfered with her vision.
“Chloë is very smart,” Jones said. “She reads at almost a third-grade level now, and she’s only 6.”
Jones did her homework, too. With no pediatric ophthalmologists near their home in Wentzville, Missouri, who would take their insurance, she asked the insurer to cover Chloë’s out-of-network care as if it were in-network. The insurer agreed to let her see an out-of-network specialist.
Chloë made it through surgery without a hitch. Jones said her daughter enjoyed a few popsicles at the hospital before going home.
“ I slept with her every night because she was so worried she would wake up and not be able to see,” she said. “But it healed beautifully, and she was absolutely ready to go back to school.”
Then the bill came.
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The Medical Procedure
Chloë was born with a droopy left eyelid, a condition known as ptosis. To correct the problem, an ophthalmologist surgically lifts the eyelid, preventing it from disrupting the patient’s line of sight.
Ophthalmologists, unlike optometrists and opticians, hold medical degrees and can provide advanced eye care, including surgery.
The Final Bill
$15,188, including $10,382 for the procedure and $2,730 for anesthesia. Initially, insurance paid just $1,775.79, leaving the Jones family owing $13,412.21 — until Chloë’s uncle, who had recently finished his term as a state senator, asked a colleague to look into it.
The Problem: Phantom Insurance Approval?
Months before Chloë inhaled bubblegum-scented anesthetic at Cardinal Glennon Children’s Hospital in St. Louis, Jones discovered that it can be hard to find a pediatric ophthalmologist. The doctor recommended by Chloë’s pediatrician wasn’t contracted with their insurer, UnitedHealthcare, and the closest in-network specialist was in Wisconsin, hundreds of miles away.
So Jones requested what’s called a network gap exception, under which the insurer would cover the recommended doctor’s services as in-network.
Before the surgery was scheduled, she received a letter saying UnitedHealthcare had approved her request “because currently there isn’t a doctor, health care professional, or facility in your area to provide these services.” The letter listed several medical billing codes for eye services and said they would be covered “at the network lev