First time mother with $40,000 hospital bill for baby’s surgery

My 6-month-old daughter had hernia repair surgery about four and a half months ago with an in-network provider at an in-network hospital. About a week before the surgery, the in-network provider obtained authorization from our insurance for the procedure as an outpatient surgery.

Before surgery, the provider noted in the medical record that my daughter “may stay overnight per anesthesia team.” However, we were told this was an outpatient surgery and were not told in advance that the hospital might bill the stay as inpatient.

The surgery went well. Afterward, she stayed overnight for observation because, due to her age, she was considered at higher risk for apnea after anesthesia. The team said we are going to keep her overnight due to apnea risk. One of the diagnoses in the medical record is “apnea after anesthesia,” although my understanding is that she did not actually have an apnea episode. She was discharged the next morning, about 24 hours after surgery.

Insurance paid several related claims, but denied the largest claim, about $40,000, as not medically necessary. The EOB lists the denied claim as a single item: “semi-private room.” However, the hospital’s itemized bill shows that the $40,000 includes operating room charges, anesthesia, pain medication, PACU monitoring, and about $10,000 for the semi-private room.

I later learned that the hospital billed the stay as inpatient and submitted an inpatient authorization request on the day of surgery, apparently after the surgery had already happened. That request was denied. We did not know about this at the time because we never received the denial letter from insurance.

We appealed multiple times and lost. I also asked insurance to reprocess the claim with patient responsibility as $0, but they refused. Insurance asked the hospital to resubmit under the outpatient auth, but hospital refused.

Insurance says we are responsible because my husband signed a financial waiver form. However, it was a standard financial responsibility form, not a waiver specific to this inpatient stay, the denied authorization, or this particular charge.

Since both the provider and hospital were in-network, we argued that the hospital was responsible for obtaining any required authorization, and that we should not be responsible if the hospital submitted it late or failed to obtain approval. Insurance says the hospital did submit for authorization, but they have not addressed that it was denied or that it appears to have been submitted after the surgery.

At this point, I’m not sure what to do next and the hospital will not "appeal", as they are done with that.