Venice, Fla. – At the risk of breakthrough treatment or blindness, a Florida woman said her doctor told her.
After experiencing her insurance, she thought she was covered. Her insurance company sent an approval letter and she proceeded with the treatment. But a few months later, she was hit by a bill that could have made her bankrupt.
In December 2023, Sharon Lawrence was on vacation with family and friends.
Doctors ultimately determined it was a thyroid eye disease, and said Lawrence recommended an infusion treatment called tepezza.
“My eyelids retreat and I don't close my eyes,” Lawrence said. “My eyes burned and watered 24 hours a day.”
Treatment was approved and payment was refused
Lawrence's health insurance Anthem Blue Cross and Blue Shield sent out two letter approval letters and called the procedure “medically necessary.”
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After she received eight prescribed injections, Lawrence said the provider put her account in the collection and claimed she was owed $373,833 because it hadn't been paid by insurance.
“It's more than a mortgage in my home. Where does that money come from?”
Lawrence spent hours on the phone while insurance, providers and businesses signed up to work with them.
“This process definitely marks the patient's last,” Lawrence said.
Lawrence discovers that she is covered by anthem insurance, but the profits are managed by a third party and personifies health. She said she went between the office for weeks trying to figure out how payments for approved treatments were denied.
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“Our healthcare system is broken and insurance companies have all the power,” Lawrence said.
Complex systems are confused even with business people
Dr. Jay Wolfson, a well-known service professor and senior vice president at the University of South Florida Health University, said patients have lost the patience of the health insurance system.
“There should be a better way, but there are no easy fixes. You're dealing with a very complex system,” says Wolfson. “Most of us don't have the time or energy to understand it. Many of us in the business don't really understand it.”
Wolfson said large sums of health insurance cannot be overlooked as companies have to answer investors and economic benefits.
Dr. Jay Wolfson discusses the health care system
ABC Action News contacted Anthem and personified their health, but both declined the chance to interview them.
Anthem has approved Lawrence's treatment, but the company said Personify is responsible for handling the claims.
“Anthem Blue Cross and Blue Shield provide members with access to a large Blue Card network. We conducted a pre-authorization assessment and thoroughly examined the health needs and network suitability before providing approval decisions for medical needs. However, the employer sponsoring Lawrence's health plan selected Health North as the benefits manager responsible for claim processing and member communications. As a result, all decisions regarding Ms. Lawrence's claims, together with related communications with her, fall completely within the full-text personification, but not the national anthem.” – Statement from Anthem Blue Cross and Blue Shield
Personify Health said the rejection was conditional on which further reviews are pending.
“Personify Health strives to provide members with comprehensive and compassionate services. We were working on the claim to get approval from Lawrence. However, they needed additional information from her provider, which added processing and review time. Once the necessary information became available, we were able to make a final decision. We are pleased that her claim was approved in line with compensation in her health plan. We can inform her provider that the claim has been resolved.” – Statement from Personify Health
Lawrence says she can't afford to wait, and her provider has unpaid bills in the collection.
“It was frustrating, infuriating and scary,” Lawrence said.
Find relief
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A few days after ABC Action News reached, Personify Health said it had approved Lawrence's claim.
“I couldn't protect myself and would have been anywhere without your help,” Lawrence said. “I'm so happy, so light and ready to take on the rest of my life.”
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