A large medical bill was wiped out after a Wake County woman reached out to your side WRAL 5.
Wendell's Melissa Koch has chronic joint disorders, making it difficult to move around and take care of three young children.
“All my joints are affected by this,” Koch explained to the 5 on your side. “None of my joints have cartilage, and small cartilage, which wears over time, will require joint replacement.”
To improve her mobility and relieve her pain, Koch participated in her second ankle replacement surgery at Duke University Hospital in October 2024. Before the surgery, she received permission from her insurance companies, Blue Cross and Blue Shield, North Carolina.
“We thought it was completely covered. We had the surgery on October 24th. About a month later, on November 21st, I mailed a letter saying, “Sorry, I decided to deny the surgery,” Koch said.
Koch appealed the decision, but was again rejected.
The denial said “service was denied as an investigation.” The amount of refusal was $126,035.12
WRAL 5 on your side asked if there was a moment when Koch thought she had to pay that amount.
“Yeah, [after] The second denial. Because most of the aftermath I didn't think they would consider other things I had to say. That's why I called WRAL,” Koch said.
WRAL 5 on your side reviewed Koch's records. The denial explained that the prosthetic cell implants are 3D printed, and was considered experimental because BCBSNCs have “there are no sufficient scientific evidence that this type of device is likely to benefit.”
BCBSNC came to this conclusion despite knowing that Koch had the same implants in the same hospital, with the same doctor four years ago with the same implant, and she said it was a success.
Our team contacted Duke University Hospital in North Carolina and Blue Cross and Blue Shield to see if Koch's case and denial were appropriate.
A few weeks later, Koch received mail from BCBSNC in the statement that the denial of the $126,035.12 bill had been overturned.
“It was very comforting to finally think, 'Now, we're not in debt of $126,000,” Koch said.
North Carolina Blue Cross and Blue Shield sent this statement to you immediately.
“We are grateful to Mrs. Koch's Blue Cross and Blue Shield for allowing her the opportunity to serve as an insurance plan and resolve this issue. I agree that this should not happen. As I outlined the members, members should not be held responsible for the surgery.”
Duke University Health System CFO Lisa Goodlett said that 3D printed models were used during Koch's care, but that was not part of the prosthesis.
“Duke developed a model, a 3D model, to make sure the implants function as expected. They never got in the patient, but somehow they thought the patient had 3D material, but they didn't have it,” Goodlett explained.
In an interview, Goodlett said that refusing health insurance has become a “stolen issue” across the board.
“We have a team of over 150 people who just deal with rejections from different payers,” Goodlett says. “Of 98% of the time, you get denial. Through this extra work, you can reverse it. So why should we experience this 98%? Would you like to pay patients or take care of them for the first time?”
a Recent research According to KFF, a nonprofit foundation focusing on health policy research, voting and journalism, it looked at network claims of 392 million since 2023, and found that insurance companies rejected 19% of these claims.
Less than 1% of rejections were appealed by consumers. When the denial was appealed, the insurance company supported 56% of these denials.
But that's not the big picture. Since most insurance companies' rejection data is not public, it is difficult to put any kind of context in the numbers we know.
Koch hopes that sharing what she has experienced will inspire others to combat these health insurance denials.
“I knew this was wrong. If they knew it, or if they believe that theirs is wrong, they could use their voices,” Koch said.
After the solution
As health insurance and claims can be confusing, discussions continued between Duke University Hospital and Blue Cross and Blue Shield and North Carolina's Blue Cross and Blue Shield after Koch's refusal to report were overturned.
During the discussion, BCBSNC said the letter that Koch denied her appeal and pointed out that the claim was $126,035.12 was not a bill. A spokesperson explained that the letter did not ask for payment. However, the letter also did not say who was liable for the amount of the claim.
The North Carolina spokesman's blue cross and blue shield said this was a misunderstanding.
The insurance company also said: “We understand that medical and health insurance coverage is often more complicated than it should be, and we are working to make it easier for our members to provide the health care they need.”
