Tuesday, July 21, 2009

The Market Works Its Healthcare Magic

From today’s Chicago Tribune front page: “They authorized back surgery but denied his $148,000 claim.
Michael Napientek of Clarendon Hills was in excruciating pain and needed back surgery. His wife has worked in the health-care field for 30 years and thought she knew how to navigate the insurance bureaucracy.
Before Napientek was wheeled into an operating room Oct. 27, his doctor obtained a preauthorization number. The surgery went well, and within weeks Napientek was feeling much better.
Until April. That's when the couple began receiving a series of letters from the insurance administrator with chilling news: Claims for the surgery had been denied, leaving them on the hook for the heart-stopping total of $148,000.
Happily for Napientek, the columnist who writes The Tribune’s “Problem Solver” column was able to get the matter reviewed by UnitedHealth, the parent company of the firm that administered Napientek’s claim. Of course, when UMR decided to pay the claim it insisted that it had nothing to do with the possibility of appearing on the front page of a major metropolitan newspaper. It was mere coincidence that it happened to complete its review within a couple days of being contacted by The Tribune.

Conservative love to invoke the boogey men of government bureaucrats making decisions that should be made by doctors and patients as if insurance company bureaucrats are benevolently devoted to the well-being of patients. BTW, the CEO of UnitedHealth made $8.2 million dollars over the last two years. Let’s hope his bonus isn’t hurt too much this year.


  1. Though it didn't go all the way, don't you think that would have been a quick slam dunk in court?

    It's sad that someone (in the company) didn't cross all the right T's, but that's hardly an excuse to put us all in Medicare.

  2. I wouldn't bet on it. Just as insurance companies are able to rescind coverage if they decide that the insured didn't disclose some information the company deems relevant, I suspect that the insurer's contract in this case reserved the right to rescind an approval if it decides that the information used to obtain the approval was insufficient.

    My wife works in the billing office of an oncology practice that has had a lot of problems with UMR. One women who thought she was covered got stuck with $4000 of fees for doctor visits because UMR refused to pay for doctor visits on the same day a patient received chemotherapy even though medicare and every other insurer does so. Now cancer patients with UMR coverage are forced to make an extra trip to the doctors office because they have to schedule them on different days than the chemotherapy.

    The woman who got stuck with the $4000 bill was out of luck because it was her employer's decision whether or not to seek arbitration of the claim. The woman's only right was to request that UMR review the claim internally.

  3. My wife informs me that ERISA shields the insurance company from law suits although an editorial in yesterday's WSJ talks about that changing.