When Greg and Sugar Bull were ready to start a family, health challenges necessitated that they work with a gestational surrogate. The woman who carried and gave birth to their twins lived two states away.

The pregnancy went well until the surrogate experienced high blood pressure and other symptoms of preeclampsia, which could have harmed her and the babies. Doctors ordered an emergency delivery at 34 weeks’ gestation. Both infants had to spend more than a week in the neonatal intensive care unit.

It was April 2020, early in the pandemic. Unable to take a plane, the Bulls drove from their home in Huntington Beach, California, to the hospital in Provo, Utah. They had to quarantine in Utah before they could see the children in the hospital.

A couple of weeks later, after the babies could eat and breathe on their own, the Bulls took them home to California.

Then the bills came.

The Patients: Scarlett and Redford Bull, newborn twins covered by a Cigna policy sponsored by Greg Bull’s employer. The gestational surrogate had her own insurance, which covered her care.

Medical Service: Neonatal intensive care when the babies were born prematurely after emergency induced labor. Scarlett spent 16 days in the NICU; Redford, 10.

Total Bill: $117,084. The hospital was out of network for the infants. Cigna paid for some of Scarlett’s care, for reasons the Bulls couldn’t figure out. The Bulls were left on the hook for about $80,000, for both babies. Their account was ultimately sent to collections.

Service Provider: Utah Valley Hospital in Provo, Utah, one of 24 hospitals run by Intermountain Healthcare, a nonprofit with about $8 billion in revenue.

What Gives: The Bulls’ ordeal points up a loophole in coverage for emergency care — even under the No Surprises Act, which took effect Jan. 1 and outlaws many kinds of surprise medical bills.

Patients who need prompt, lifesaving treatment often don’t have time to find an in-network hospital. In the past, health plans sometimes have said they would pay for emergency care even if it’s out of network. The No Surprises Act now makes this a legal requirement in every state. The provider and insurer are supposed to negotiate a reasonable payment, leaving the patient out of the equation.

But what if the insurance company denies that the care is for an emergency? Or the hospital doesn’t supply the paperwork to prove it?

That’s what happened to the Bulls. Cigna said it lacked documentation that the NICU care for the twins qualified as an emergency.

So the Bulls began receiving insurance explanations showing huge balances owed to Utah Valley. The family had expected to owe its out-of-network, out-of-pocket maximum of $10,000 for the twins’ care. They assumed most of the bills would be paid by Cigna soon. They weren’t.

“I was, like, there is no way this can be real,” said Sugar Bull, an interior designer.

“Dear Scarlett Bull,” began one of Cigna’s letters, addressed to a 6-month-old baby. “We found the service requested is not medically necessary.”

How could NICU care not qualify? The gestational surrogate was admitted to obstetrics by her doctor without going through the emergency department, which prompted Cigna to initially conclude there was no emergency, said Dylan Kirksey of Resolve Medical Bills, a consultancy that eventually worked with the Bulls to resolve the claims.

To establish that there was, Cigna asked for daily progress notes and other medical records on the infants. The Bulls tried to get the hospital to comply. Cigna kept saying it hadn’t received the necessary documentation.

The Bulls appealed. Sugar spent hours with insurance paperwork and hold music. But almost a year later, about $80,000 in bills remained. Utah Valley sent the accounts to collections, Sugar Bull said. It was the last thing she had time for.

“I own a company, and I am super busy, and we had twins,” she said. “Every two weeks or so, I would feel a panic and righteous anger about it. And I would keep pushing and calling, and it would take like five hours every time.”

Though they disputed what they were being charged, the Bulls agreed to pay the hospital $500 a month for five years to settle just one of the babies’ bills, in an attempt to keep their good credit.

Not a Modern Healthcare subscriber? Sign up today.