"Denials may be triggered because requested services are inconsistent with the latest clinical guidelines and evidence-based medicine, thereby putting patient-safety and good clinical outcomes at risk," Traynham said in a statement.

Health care providers, however, say it's clear that they're running into more trouble with health insurance denials, including those stemming from technicalities or paperwork issues that should be much easier to resolve.

With medical-necessity denials, insurers sometimes refer to internal guidelines that vary from national standards set by professional groups, argued Terrence Cunningham, director for administrative simplification policy at the American Hospital Association. Another problem, Cunningham said, is that insurer policies vary from one another and are frequently updated, making it hard to comply with all the rules.

"There's been a lot of talk over the last couple of years about surprise bills and what happens when people go out-of-network," said Molly Smith, the group vice president for public policy at the American Hospital Association. "Probably the bigger surprises are when people have insurance, and they're going in-network ... and then their coverage fails them. We really think this is an area for increased oversight."

In a statement, AHIP countered that hospitals seem to think "it's perfectly fine to charge and demand extreme prices for medical services without any consideration about the impact of those prices on consumers' premiums or their cost-sharing."

Park Nicollet was an in-network provider for Knirk's health plan. The insurance limited out-of-pocket spending for covered expenses to less than $4,000, so Knirk was shocked when Park Nicollet's letter in March said she was responsible for $32,449.52.

Knirk said the letter was also frustrating because it said she hadn't asked Park Nicollet to file an appeal on her behalf. A notebook — with records of the 32 phone calls she completed over seven months trying to get the matter resolved — says otherwise.

Park Nicollet told her in September she would have to lead the appeal, Knirk said, and then later filed its own appeal — duplicating work to assemble medical records she would have been happy to avoid.

HealthPartners says there was an "unfortunate" misunderstanding on the appeal process, and added in a statement: "We're committed to partnering with our patients to help them navigate insurance coverage."

Knirk said she also received confusing messages from Horizon Blue Cross Blue Shield on what constituted a "first-level" and "second-level" appeal in her case. In February, when she spoke with the insurer for a status update, Knirk was dismayed to hear from a customer service representative that the appeal had been sitting in a queue, not yet activated.

Without responding to all of Knirk's specific concerns, the insurer said in a statement: "This is an important reminder that patients deserve and need providers and health insurers to work together fulfilling our individual and collective responsibilities to make health care work the way we all want."

Knirk is happy to now to be out from under the threat of a huge medical bill. But she's sharing her story to warn consumers about how things can go wrong — and implores others to push insurers and health care providers to do better.

"I still think: 'Why weren't Blue Cross Blue Shield and Park Nicollet more in communication on this?'" she said. "This whole appeals system is so complicated. I don't know why things have gotten so gummed up."

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