Chicago Tribune: They authorized back surgery but denied his $148,000 claim
CONSUMER WATCH
by Jon Yates/What's Your Problem?
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.
"I hit the roof," said Sandie Napientek, Michael's wife.
The couple's descent into health-insurance hell left them worried not just about how to pay the bill, but also puzzled over how "preauthorized" surgery could not be covered.
Napientek said she appealed the decision three times -- and was rejected each time.
"They're just throwing out any excuse they can possibly find," she said. "It's just a ridiculous game."
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?"
Sandie Napientek said that under the terms of her health-care plan, UMR administered the benefits but her employer funded the payments. After claims reached a certain threshold, she said, it was paid for through a separate stop-loss insurance plan.
Napientek said she spoke with her boss and her director of human resources, but neither could get UMR's decision reversed.
"It's just horrific," she said after e-mailing What's Your Problem? in late June. "The stress of all this has just been unbelievable. I've had many sleepless nights."
If UMR did not change its mind, the Napienteks said, they would have to find the money somewhere.
"I doubt they'd accept $10 a month," Sandie Napientek said.
The Problem Solver called a spokeswoman for UMR, who forwarded the call to Greg Thompson, a spokesman for UnitedHealthcare, which owns UMR. UnitedHealthcare also provides health insurance for Tribune Co., owner of the Chicago Tribune.
Thompson promised to check the status of the Napienteks' complaint.
On Saturday, the couple received a letter from UMR saying it would pay for the surgery after all.
The letter said UMR reversed its denial "based on additional information submitted and the opinion of an independent physician."
The Napienteks could hardly believe their eyes.
"Could you say elated was an understatement?" Sandie Napientek said Monday. "It's just beyond relief."
Napientek said the couple already had met their out-of-pocket maximum expenditure for last year, so UMR's reversal meant insurance would pay the entire $148,000 in medical bills.
Thompson disputed the Napienteks' claim that they had appealed three times. He said such cases normally are reviewed twice.
Thompson said UMR's decision last week to pay the claims had nothing to do with the Problem Solver's inquiry. He said UnitedHealthcare uses an external review process for any claim a customer believes requires further review. In such cases, an outside physician reviews the claim. For the Napienteks, the external review finally was completed last week, Thompson said.
"This is a perfect example of how the process works," said Thompson, who did not return a subsequent call Monday to address why a preauthorization number doesn't necessarily mean a guarantee of coverage. "The process might not work as fast as people want it to work, but it works."
Michael Napientek said he's not so sure.
"I'd love to have whoever made the previous decisions -- just five minutes in a room with him -- and grill him for a while," he said.
Instead, he'll settle for a vastly improved back and the knowledge he will not have to pay $148,000 for it.
"I couldn't fall asleep last night, I was so excited," he said.
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