Insurer Preauthorization Doesn’t Guarantee Payment for $148,000 Back Surgery

balancing-a-checkbook-paying-billsHere’s a story that illustrates one way that our healthcare delivery system is broken.  Michael Napientek has been through healthcare insurance hell – and survived the ordeal. Last fall, the doorman underwent back surgery after obtaining a preauthorization number for payment from his insurance company.  Napientek’s health insurance is provided by his wife Sandie’s employer, Accelerated Health Systems.  The policy is a self-insured plan funded by Accelerated Health Systems, and which is administered by Wausau, WI-based UMR, a UnitedHealthcare subsidiary.

Imagine the Napienteks’ surprise when bills totaling $148,000 started appearing in their mailbox.  The insurer was refusing to pay for the surgery, even though it had preauthorized the procedure.  Three appeals against the claim were denied on the grounds that Napientek had not exhausted all means of pain relief.  Sandie Napientek complained to a UMR representative and was told that preauthorization did not guarantee payment because they had not provided documents that proved the “appropriateness” of the surgery.

Frustrated, the Napienteks turned to the Chicago Tribune’s “What’s Your Problem?” columnist Jon Yates to see if he could intervene.  Yates contacted UMR, who referred him to United Healthcare.  The Napienteks’ next communication from UMR was a letter saying it would pay the entire $148,000.  According to the letter, UMR changed its mind “based on additional information submitted and the opinion of an independent physician.”

This story represents a classic example of an insurance company bureaucrat standing between the patient and his physician – after preapproved surgery had been performed.

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