To get a clearer understanding of the medical billing frustrations that affect so many people, we invited readers to share their billing and insurance problems with us. More than 100 people did. Here are nine of their stories.

BRIAN AND EVELYN ROACH

Evelyn Roach of Gray gave birth to her first child in October.

Eamon was born six weeks premature and needed to stay in Maine Medical Center’s neonatal intensive care unit for about two months. While he’s now healthy and at home, Roach and her husband, Brian, spent months fearing they would wind up hundreds of thousands of dollars in debt for their new baby’s medical care.

The couple brought Eamon home Dec. 31. They had set aside money for the pregnancy and birth because they have a high-deductible insurance plan and expected out-of-pocket costs totaling a few thousand dollars. But shortly after bringing the baby home, the couple got letters from her insurance company stating their claims were denied and that they would be on the hook for the full cost of his care:  $360,000.

She and her husband made numerous calls to Anthem and MaineHealth, the parent organization of Maine Med. She said they never got a clear answer about why the claim was denied.

“It’s a massive amount of money. It’s almost incomprehensible,” Brian Roach said while still trying to get answers in May. “How would we go about paying for this?”

“No one (ever) said this is wrong and you won’t be charged for it,” Evelyn Roach said.

Finally, in June they got a bill from Anthem in Maine showing they didn’t owe any money. They had already met their out-of-pocket deductible of $6,600 earlier in 2021.

“We were so relieved,” Evelyn Roach said shortly after receiving the news. “It was adding unnecessary stress to an already stressful situation.”

But they still do not know why the claim was initially denied.

“It’s unclear to me what happened,” Evelyn Roach said. “Whenever I spoke with someone, they were always kind and trying to be helpful, but I could tell no one really could tell me what was going on.”

She said they notified the insurance within a week of Eamon being born that he was being added to her insurance policy, meeting that insurance requirement.

Evelyn and Brian have different insurance policies through their employers, so they think this may have been an effort by Anthem of Maine – Evelyn’s policy – to get Anthem of Illinois – Brian’s insurance coverage – to cover the birth. But no one has confirmed that.

Evelyn Roach said the experience made her feel helpless.

“Eamon needed to be in the hospital after he was born, and we shouldn’t have had this hanging over our heads,” she said. “Why was this so stressful and confusing?”

ALEX ST. HILAIRE

Alex St. Hilaire needed a CT scan twice in the past two years for abdominal pain he was experiencing.

The tests were identical. In both cases the 31-year-old’s symptoms turned out to be false alarms. But the two bills he received were starkly different.

In February 2021, St. Hilaire went to Shields Imaging in Brunswick for a CT scan and ended up with a bill of $742. Because he has a high-deductible health insurance plan, St. Hilaire knew he was going to pay the bulk of the cost, and the bill was in the ballpark of what he was expecting.

In February 2022, the Westbrook resident needed another scan. He was having difficulty scheduling one, so he asked his doctor’s office to give him other places to try. He was referred to Northern Light Mercy Hospital in Portland, where he went for the same CT abdominal scan conducted at Shields Imaging the previous year.

The cost: $2,900.

“I was expecting $600 to $700. I was not expecting $3,000,” St. Hilaire said. With the high-deductible plan, he was on the hook for most of the money, although he was able to get a discount to $2,500 by immediately paying in full.

All for a procedure that took less than five minutes.

“I remember the tech saying, ‘All right, done.’ I was literally in the machine 40 seconds tops, and it cost $3,000,” St. Hilaire said. “It didn’t ruin my year, but certainly I could have done something else with that money.”

St. Hilaire said it doesn’t make any sense that the same procedure could have such wildly different costs.

It’s a painful lesson learned by countless health care consumers in the U.S., where all kinds of medical costs vary widely for the same procedures. In Maine, for example, a hip replacement can cost $30,000 in one hospital and $60,000 in another.

“Why are we paying crazy bills like this?” he said.

ED LATHAM

When Ed Latham experienced chest pains in May, he checked himself into Northern Light Maine Coast Hospital in Ellsworth for observation.

The 53-year-old had three previous heart attacks, so he relied upon his cardiac surgeon’s “strong recommendation” that he be hospitalized for observation and tests. Latham said he was concerned about whether insurance would cover his six-day hospital stay, but he wasn’t going to go against his doctor’s recommendation.

“I understand their thinking of it’s better to be safe than sorry,” said Latham, who lives in Milbridge. “They didn’t want me walking out of the hospital and dropping dead on the street a few blocks away.”

Latham’s heart was OK, and he was released. A few weeks later he got a letter from his insurance company stating that the claim for his hospital stay would be denied and not covered. There was no explanation. He still has not received a bill from the hospital saying how much he could potentially owe.

Latham said he called the hospital’s billing department, and they told him that it will likely be worked out between the hospital and Anthem, his insurance carrier. But in the meantime, the possibility that he could owe thousands continues to weigh on him – he still has not been told how much the bill could be.

“Why am I involved in this at all?” Latham said. “They shouldn’t be putting me in the middle of a dispute between the hospital and the insurance company about what is payable and not payable.”

Latham said the entire situation is alarming.

“The insurance company is essentially saying it is logical to go against your doctor’s wishes for their financial considerations,” Latham said.

DAVID SANBORN

Once a year David Sanborn of South Berwick gets an endoscopy for his throat to make sure a pre-cancerous condition doesn’t return.

And every year he has to fight with his insurance company over the bill.

His medical provider is in the insurance company’s network, but his doctor sends the biopsy to an out-of-network lab. His insurance company, Cigna, has billed him for the entire cost of the lab work – $4,300 – every year.

“Every single time it’s been a different problem, and every time they are trying to stick me with a lab bill,” Sanborn said. “Their policies are consistently changing. It’s aggravating. It’s a procedure I am going to need next year and the year after that and for the rest of my life. It should be paid.”

So far, the 46-year-old has been able to eventually get the cost covered. But he said it’s infuriating to have to go through the hassle every time.

Sanborn said he could have his doctor seek a different lab, but doesn’t want to compromise on his care.

“When my doctor decides this is the best lab to send the sample to, I’m not inclined to argue with my doctor,” he said. “He’s the expert.”

DONI GALLINGER

Doni Gallinger fought for years with two insurance companies over coverage for mental health services.

When the 70-year-old enrolled in Medicare five years ago, she also purchased insurance that provided supplemental coverage for mental health. Gallinger said she was assured that her therapist – Jill Copeland, a licensed clinical professional counselor – would be included in her insurance plan.

Nevertheless, Gallinger said, the companies denied the claims.

“They just wouldn’t bloody do it. They just wouldn’t,” she said.

Gallinger said she ended up having to pay $1,500 out-of-pocket before her mental health services were finally covered, but she spent many hours on the phone and writing letters to get the service covered. The hold-up was over the fact that standard Medicare does not reimburse for counseling by an LCPC even though her supplemental insurance plan was supposed to.

“The only answer I would ever get is that, ‘We won’t cover it because Medicare doesn’t,'” said Gallinger, who wrote letters to Sen. Angus King and to Rep. Chellie Pingree to put pressure on the insurance companies. “There was a very clear intent to withhold services. That was a very clear objective for them.”

The only reason she eventually broke through and got it covered was by being extremely persistent with letters and appeals. In one May 2019 letter to Aetna, Gallinger was so frustrated that she wrote: “(May) God forgive you for harassing people with health problems, rather than giving them the services they have contracted and paid for.”

Gallinger, who lives in Portland, said that in all the time she has dealt with insurance companies, “they don’t ever seem to make mistakes where there’s a benefit in your favor.”

She lived in Canada as a young woman and remembers learning about how the U.S. system was so different from the simpler Canadian system, which covers people without sending them into medical bankruptcy.

“When I was in Canada, we always watched in horror what was happening in the U.S. (with the health care system),” Gallinger said. “We wondered why they put up with it. The system is barbaric.”

SIMONNE MALINE

Simonne Maline has osteoarthritis in both knees. She uses walking sticks to get around, and for more than a decade she has relied on periodic injection treatments to keep the pain manageable and avoid surgery.

Now, however, the 56-year-old is so far unable to get the same treatment that has helped her in the past because it may not be covered by her plan.

“It’s discouraging and frustrating and makes me angry that my life is limited because of insurance and money,” said Maline, who lives in Winthrop. “And it’s not even based on science. It boggles my mind. Life shouldn’t have to be this hard to get care.”

Maline said her insurance company turned her down two years ago when she requested SynVisc-One injections. She is being required to try another treatment first before her doctor can request the SynVisc-One injections again, and it’s not clear another request would succeed.

She fell on the cement floor in her garage last fall, further aggravating her left knee. The treatment injects a gel that lubricates the knee. The company’s website says some insurance plans will cover the procedure, while others won’t.

The cost of a SynVisc-One is about $1,000 to $2,000 plus the cost of a health professional to give the injection. It’s far less than the $30,000 or higher price of knee surgery, which she said she will likely need if she can’t get the treatments.

The injections – which she has undergone three times in the past 15 or so years – have provided years of pain relief and mobility. But in recent years insurance companies have balked at paying for the treatments because it’s ineffective in some cases.

“I have a proven history of the treatments working for me, so this should be the first line of defense for me,” said Maline, who happens to be executive director of the nonprofit Consumer Council System of Maine, which advocates for improvements in public policy for mental health services.

Instead, she will have to try cortisone shots that, based on past experience, she believes will not work. If the gel injections are not approved after that, she will have to wait more than six months for knee surgery.

And not only would a knee replacement surgery be more costly for the system, but the recovery time from surgery would mean she could not care for her husband, who uses a wheelchair and is disabled from a brain injury. Knee surgery for Maline would mean her husband would need to go to a nursing home.

Maline also has about $25,000 in medical debt as a breast cancer survivor and needing three surgeries related to her cancer and other medical problems. For three years in a row, she hit her $7,000 out-of-pocket maximum with her insurance plans. So even though she’s insured, it’s put her into debt.

“When you look at what you have to pay out of pocket, it becomes a huge financial burden that becomes insurmountable,” Maline said.

VALERIE LAWSON

Valerie Lawson said she knew she was rolling the dice in early 2021 when she chose to be without health insurance temporarily.

At age 64 and only a year away from qualifying for Medicare, she could no longer afford to pay her health insurance premiums through the Affordable Care Act. A few weeks later, the Biden administration increased subsidies for middle-class people like Lawson nearing retirement age, and she quickly signed back up.

But during the month that she was uninsured, Lawson experienced hemorrhaging in her colon and had to be hospitalized at Northern Light Eastern Maine Medical Center in Bangor. Her condition didn’t require surgery, but the bill for a two-day hospital stay totaled $21,000.

“When I first heard the total amount on the phone, I felt like the floor opened up beneath me, and I fell through. I thought, ‘You have to be kidding me.’ I was really gobsmacked,” said Lawson, who lives in the Washington County town of Robbinston.

So Lawson – still weak from her hospital stay – took it upon herself to examine every aspect of her bill, to see what could be challenged.

“It was exhausting,” she said. “I was still quite ill. I couldn’t even stand up for 5 minutes at a time, I was so weak.”

She looked over the charges and found they were consistently higher than the official “chargemaster” prices published on the hospital’s website. The chargemaster prices are the initial price set by the hospital, but they are often different than the charges negotiated with individual insurance companies. In one case, an iron IV infusion to help speed her recovery cost more than $3,000, when the chargemaster price indicated it should have been only about $50.

“If I had known how much that was going to cost me, I would have said, ‘No, thank you, I’ll have a steak at home,” Lawson said. She said Northern Light never gave her a reason for the price.

The hospital offered her a 25 percent discount on the overall bill, which she took, and is now paying off about $14,000.

While Lawson now qualifies for Medicare – and with supplemental insurance shouldn’t have to worry about getting socked with any more giant bills – she said the money she spent means that she will have to delay her retirement from her work in website design.

“You really go through the wringer when this happens,” Lawson said. “It just grinds you down, just no way out of it. I eventually just gave up.”

SEAN DUNDON

Christmas 2021 started painfully for Sean Dundon.

He was at home in Portland doing some morning food prep. “The first slice of peeling potatoes, I sliced a portion of my finger off,” he said.

Dundon, 54, said he wanted to make sure it wasn’t a serious injury, so he went to the Northern Light Mercy Hospital Emergency Department in Portland. He said he would have gone to an urgent care center but they were all closed for the holiday.

“They gave me Lidocaine (anesthetic), cleaned out the wound, wrapped it up and sent me home in half an hour,” Dundon said. He didn’t need stitches.

“I came home and opened presents and thought, ‘This was great.'”

The bill arrived a few weeks later: $800, which included a $510 “facility fee” for using the hospital on top of about $300 in charges for the assessment and treatment.

“If there had been a sign on the wall that said there was a facility fee, I would have gone home, dressed it myself and gone (somewhere else) the next day,” Dundon said.

A facility fee is charged by health care providers to cover the expense of the overall services in the building, but insurance companies will often pay only a fraction of the fee, leaving patients on the hook for the bulk of the cost.

Dundon said he tried to appeal and negotiate a lower bill but was unsuccessful. With a high-deductible insurance plan, he had to pay the entire cost himself.

“They are basically admitting they are gouging me,” Dundon said. “It is intentionally obfuscating and confusing.”

BILL BARTLETT

Bill Bartlett’s doctor recommended he get a routine cardiac stress test.

So the 60-year-old from Kennebunkport called his insurance company in advance to find out how much it would cost, giving them the name of the York Hospital-affiliated doctor’s office to make sure it was in-network and wouldn’t cost too much.

The answer: He would be responsible for $45.

It sounded reasonable, so Bartlett went for the test at York Hospital in November. The test did not show any problems with his heart.

When he got the bill in February, it was for $858 – $45 for the stress test plus $813 that was tacked on for reasons that weren’t clearly explained.

When he asked what the $813 was for, Bartlett said his insurance company, Harvard Pilgrim, told him it was a hospital facility fee, an add-on because the test occurred in a hospital. And he was told the insurance plan doesn’t cover most of the facility fee. The total facility fee was $924. Harvard Pilgrim paid $111, and the $813 balance was charged to Bartlett. After months of back-and-forth, Harvard Pilgrim paid the bill, without explanation, in late July.

Bartlett said when he initially called to complain about the charge, hospital officials were at first vague about the $813 but later confirmed that it was a facility fee.

“When a patient receives services at York Hospital, their invoice will include a facility fee,” said Jean Kolak, a spokeswoman for York Hospital, in a statement to the Portland Press Herald/Maine Sunday Telegram.

“The amount of this fee is created, based on variety of factors, such as the cost of staff, equipment, technology, medications utilized, supplies and in some clinical care areas, the acuity of the patient,” Kolak said. “Additionally, in cases where the physician/provider is employed directly by York Hospital, a separate professional fee will also be charged.”

Kolak said the cost of the cardiac stress test and all other services at the hospital are built into the facility fee, so it is incorrect to say the stress test cost $45.

Bartlett said he thinks he should have been told about the total cost when he called the insurance company to ask about the price.

“If I’m interested in buying a car, you don’t say, ‘How much are the tires?’ No, you’re asking what the whole price of the car is,” Bartlett said. “Harvard Pilgrim quoted me the price. Any additional costs are on them (York Hospital).”

Kolak said “payments for services are based on contracted rates with each payer” and that according to the contract with the insurance companies, and in the case with Medicare or Medicaid patients “we cannot waive patient responsibility” for charges.

The hospital offered to give him a payment plan, but Bartlett balked.

“Why should I go on a payment plan for something I don’t owe?” Bartlett said.

Bartlett refused to pay, and an initial appeal to Harvard Pilgrim was rejected before being paid in late July without explanation.

“They have these charges that are invisible to consumers,” Bartlett said. “This shouldn’t be my problem, I did my due diligence ahead of time to determine the cost. It’s not like I have some exotic disease. They should know what this is going to cost.”

Bartlett said that had he not been semi-retired and in good health, he may not have had the time and energy to fight the bill.

“I often wonder how many times medical providers send these bills out, and get a check back because nobody’s going to argue or spend the time to fight it?” Bartlett said.

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