Chlo\u00eb 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\u2019s line of sight.<\/p>\n
Ophthalmologists, unlike optometrists and opticians, hold medical degrees and can provide advanced eye care, including surgery.<\/p>\n
The Final Bill<\/strong><\/p>\n $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 \u2014 until Chlo\u00eb\u2019s uncle, who had recently finished his term as a state senator, asked a colleague to look into it.<\/p>\n The Problem: Phantom Insurance Approval?<\/strong><\/p>\n Months before Chlo\u00eb inhaled bubblegum-scented anesthetic at Cardinal Glennon Children\u2019s Hospital in St. Louis, Jones discovered that it can be hard to find a pediatric ophthalmologist. The doctor recommended by Chlo\u00eb\u2019s pediatrician wasn\u2019t contracted with their insurer, UnitedHealthcare, and the closest in-network specialist was in Wisconsin, hundreds of miles away.<\/p>\n So Jones requested what\u2019s called a network gap exception, under which the insurer would cover the recommended doctor\u2019s services as in-network.<\/p>\n Before the surgery was scheduled, she received a letter saying UnitedHealthcare had approved her request \u201cbecause currently there isn\u2019t a doctor, health care professional, or facility in your area to provide these services.\u201d The letter listed several medical billing codes for eye services and said they would be covered \u201cat the network level.\u201d<\/p>\n About a week later, the insurer sent a prior authorization letter approving Chlo\u00eb\u2019s surgery.<\/p>\n But UnitedHealthcare declined to pay most of the surgery bill, covering it as out-of-network. With approval letters in hand, Jones said, she did not understand why the insurer apparently was not honoring its agreement to cover her daughter\u2019s treatment.<\/p>\n In fact, the similar-looking letters granted different kinds of approval.<\/p>\n UnitedHealthcare\u2019s gap exception approved Chlo\u00eb\u2019s exams before the surgery as in-network. But in its prior authorization letter for her surgery with the same doctor, the insurer said only that it would cover it \u2014 without offering network discounts.<\/p>\n After receiving the bill, Jones contacted the insurer online, but she said a representative told her there was no record of its approval to cover the surgery as in-network.<\/p>\n \u201cAt that point, I didn\u2019t even know what to do,\u201d she said. \u201cI\u2019m like, \u2018This is crazy.\u2019\u201d<\/p>\n She said she sent over a copy of one of the approval letters, which was on the company\u2019s letterhead, but a representative told her the letter hadn\u2019t come from UnitedHealthcare.<\/p>\n \u201cThey said, \u2018You saw this surgeon, they\u2019re not covered and you didn\u2019t have permission, so, no, we\u2019re not going to pay,\u2019\u201d Jones said, recounting the phone call.<\/p>\n An insurance representative told Jones she owed more than $13,000 because of \u201ca balance billing issue.\u201d That meant the Jones family would have to pay the $13,000-plus balance.<\/p>\n Spokespeople for UnitedHealthcare confirmed the company provided a gap exception and prior authorization for Chlo\u00eb\u2019s care. Eric Hausman, a spokesperson for UnitedHealth Group, said in a statement to KFF Health News that \u201cwe empathize with anyone who finds themselves in the unfortunate situation of being balance billed by an out-of-network provider for an amount significantly above market rates, and without any advance knowledge.\u201d<\/p>\n Maryanne Wallace, a spokesperson for SSM Health, the health system that includes Cardinal Glennon Children\u2019s Hospital, provided a statement that said SSM followed \u201cstandard patient billing procedures.\u201d<\/p>\n \u201cOccasionally, an insurance company may process a claim as an out-of-network service, which can result in a balance being billed to the patient,\u201d the statement said.<\/p>\n The Resolution<\/strong><\/p>\n Jones said she was blindsided by the big bill. She tried to fix the problem on her own, she said, keeping track of every interaction with the insurer and the hospital. She filed appeals with UnitedHealthcare.<\/p>\n Nothing helped \u2014 until she reached out to her brother Caleb Rowden, who had been a Missouri state senator for eight years after serving four years in the state House.<\/p>\n \u201c\u200aI\u2019ve never used my brother\u2019s political clout for anything,\u201d she said. \u201cI actually hate politics.\u201d<\/p>\n Rowden told KFF Health News that he reached out to Travis Fitzwater, the state senator representing his niece\u2019s district. Jones contacted Fitzwater\u2019s office, too, and sent a complaint to Missouri Attorney General Andrew Bailey.<\/p>\n Fitzwater said his office did no more for Chlo\u00eb than it would for any constituent.<\/p>\n \u201cWe\u2019re not going to take a lot of credit for the result of it, because we didn\u2019t ask for anything other than a resolution, so that everybody can be at peace and move on with their lives,\u201d he said in an interview. \u201cWe just did what we do every day.\u201d<\/p>\n After Fitzwater\u2019s staff contacted the hospital and the insurer, representatives from both separately called Jones and notified her that UnitedHealthcare had paid the bill in full.<\/p>\n In the end, Chlo\u00eb\u2019s family paid nothing for her procedure \u2014 not even a copay.<\/p>\n The Takeaway<\/strong><\/p>\n When it comes to insurance approvals, read the fine print carefully; \u201ccovered\u201d does not mean an insurer will pay, let alone at in-network rates.<\/p>\n Rowden and Fitzwater said reaching out to your elected representative\u2019s office can help. Advocating for constituents is part of their job.<\/p>\n \u201cThey usually have an open line of communication with these insurance companies and hospitals,\u201d Rowden wrote in an email. \u201cThey may not always be able to get to a positive outcome since every situation is a little different, but they can usually get you to a next step.\u201d<\/p>\n Jones is grateful that her brother was able to help, though she acknowledged that she probably would not have called him without a nudge from their mother. \u201cI think I would still be fighting,\u201d she said.<\/p>\n Bill of the Month is a crowdsourced investigation by KFF Health News<\/a> and The Washington Post\u2019s Well+Being<\/a> that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it<\/a>!<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n![](\"http:\/\/www.dangeladvertising.com\/wp-content\/uploads\/2025\/08\/Jones_005-resize-scaled.jpg\")
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