VENICE, Fla. — Get a groundbreaking treatment or risk going blind, a Florida woman said her doctor told her.
After going through her insurance, she thought she was covered. Her insurance company sent an approval letter and she went ahead with treatment. But months later, she was hit with a bill that could have bankrupted her.
In December 2023, Sharon Lawrence was on vacation with family and friends when she said she started having double vision to the point she was so dizzy she could barely walk.
Doctors eventually determined it was thyroid eye disease, Lawrence said they recommended an infusion treatment called Tepezza.
“The eyelids retract so the eyes don’t close,” Lawrence said. “My eyes were burning and watering 24 hours a day.”
TREATMENT APPROVED, PAYMENT DENIED
Lawrence’s health insurance, Anthem Blue Cross and Blue Shield, sent two letters of approval, calling the procedure “medically necessary.”
After she received the eight prescribed infusions, Lawrence said the provider put her account in collection because they hadn’t been paid by insurance and claimed she owed $373,833.
“That’s more than the mortgage on my home. Where would that money come from?”
Lawrence spent hours on the phone between her insurance, her provider, and the companies contracted to work with them.
“This process definitely puts the patient last,” Lawrence said.
Lawrence discovered that she is covered by Anthem Insurance, but the benefits are administered by a third party, Personify Health. She said she went between the companies for weeks trying to figure out how payment was denied for an approved treatment.
“Our healthcare system is broken and the insurance companies have all the power,” Lawrence said.
COMPLEX SYSTEM, CONFUSING EVEN TO THOSE IN THE BUSINESS
Dr. Jay Wolfson, a distinguished service professor and senior associate vice president of University of South Florida Health, said patients are losing their patience with the health insurance system.
“There should be a better way but there is no easy fix, you’re dealing with a remarkably complex convoluted system,” Wolfson said. “Most of us don’t have the time or the energy to understand it, many of us in the business don’t understand it very well.”
Wolfson said the big money involved in health insurance can’t be overlooked, since the companies must answer to investors and financial interests.
ABC Action News reached out to Anthem and Personify Health, but both turned down the chance for an interview.
Even though Anthem approved Lawrence’s treatment, the company said Personify was responsible for processing the claim.
“Anthem Blue Cross and Blue Shield provides members access to the extensive Blue Card Network. We conducted a pre-authorization assessment and, after thoroughly verifying medical necessity and network suitability, provided a medical necessity approval determination. However, the employer sponsoring Ms. Lawrence’s health plan selected Personify Health North as the benefits administrator responsible for claims processing and member communications. As a result, all decisions regarding Ms. Lawrence’s claim, along with any related communications with her, fall entirely under Personify Health North’s jurisdiction—not Anthem’s.” – Statement from Anthem Blue Cross and Blue Shield
Personify Health said the denial was conditional pending further review.
“Personify Health strives to provide our members with comprehensive and compassionate service. We had been working on Ms. Lawrence’s claims to get them approved; however they required additional information from her provider, which resulted in additional time for processing and review. Once the needed information was available, the final determination was able to be made. We are happy that her claims have now been approved in alignment with her health plan coverage. We are available to notify her providers that the claims have been resolved.” –- Statement from Personify Health
Lawrence said she couldn’t afford to wait, her provider has the unpaid bill in collections.
"It was frustrating, infuriating and scary,” Lawrence said.
FINDING RELIEF
Days after ABC Action News reached out, Personify Health said it approved Lawrence’s claim.
“I could not protect myself and I couldn’t get anywhere without your help,” Lawrence said. “I’m feeling so happy, so light, and ready to take on the rest of my life.”
Marine veteran helping others after overcoming alcoholism and homelessness
“If I can do anything to help them get out of that pain and misery and suffering that they are going through, and if I can help them progress and move forward, that’s really all I want to do,” said Cameron Wright.