You've waiting patiently and in pain while all the wheels are greased and the Insurance Company Death Panel made up of unemployable doctors, nurses, and accountants decides your fate. Finally, they come through and tell you that you can go ahead and have your surgery. You're elated! But not so fast...
In October 2008, Michael Napientak, a doorman from Clarendon Hills, Ill., went to the hospital for surgery to relieve agonizing back pain. His wife's employer's insurance provider, a subsidiary of UnitedHealthCare, had issued a pre-authorization for the operation. The operation went well.
But in April, the insurer started sending notices that it wouldn't pay for the surgery, after all; the family, not the insurance provider, would be on the hook for the $148,000 the hospital charged for the procedure. Pre-authorization, the insurance company explained, didn't necessarily guarantee payment on a claim would be forthcoming.
The couple's health insurance was provided by Sandie Napientek's employer, Accelerated Health Systems. The policy was a self-insured plan, meaning Accelerated Health Systems funded the plan, which was administered by a company called UMR out of Wausau, Wis.
Napientek said she called a UMR representative to complain and was told preauthorization did not guarantee payment. UMR initially said her husband had not exhausted all conservative means of pain relief. Later, after the couple showed evidence he had, in fact, tried conservative pain-relief methods, UMR said he had not provided documentation to support the "appropriateness" of the surgery.
"I don't have [$148,000]," said Michael Napientek, lead doorman for a high-rise in Palatine. "I'd almost rather have the bad back than to spend [$148,000], but what are you going to do?" Napientak's wife, Sandie, asked her boss to help out, but with no luck.
Fortunately for the Napientaks, they were able to attract the attention of a Chicago Tribune columnist before they had to figure out how to pay the six-figure bill -- once the newspaper started asking questions, the insurer suddenly decided, "based on additional information submitted," to cover the tab, after all.
Yes, there you have it. The only paperwork that counts is media exposure of the company's "Death Panel." Once it appeared the secret would be out they decided to "buy off" the family by paying the bill they had promised to pay originally!