That question might be a joke to orthopedic surgeons, but it turned into a nightmare for Jim Furlan when his teen-age daughter was injured at a volleyball tournament. After an MRI was performed and surgery was scheduled, Aetna refused to pay the $6,000 bill for the MRI on the grounds that it had not been pre-approved. It only got worse when Furlan appealed on the grounds that his daughter’s ACL surgery could not be performed without an MRI:
But Aetna stuck to its guns. It denied Furlan’s appeal on the grounds that “precertification was required for the MRI and there is none on file.”
Never mind that if the insurer’s bean counters had stopped to think about things for just a moment, they’d probably have agreed with the medical experts that an MRI is a key part of ACL surgery.
Meanwhile, Torrance Memorial Medical Center started billing Furlan because he’d signed a waiver declaring that if his insurer didn’t pony up, he’d have to cover the tab. The hospital’s invoices warned that if he didn’t make good, “your account will be referred to a professional collection agency.”
Frustrated, Furlan took his case straight to the top, writing a letter last month to Aetna’s chief executive, Mark Bertolini. He said he received no answer. So he came to me.
An Aetna spokeswoman, Cynthia Michener, deemed the whole mess “a big misunderstanding.”
Have you ever tussled with your health insurer over a pre-approval or pre-authorization? Tell us about it in our health insurance forum!
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