CBS 5 Advocate

Health insurer pre-approvals may not address likely cost to patients

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Mike Smith got pre-approval for the treatment of his foot but the code on the approval letter was for surgery, not an office visit like he thought. (Source: CBS 5) Mike Smith got pre-approval for the treatment of his foot but the code on the approval letter was for surgery, not an office visit like he thought. (Source: CBS 5)

A Glendale man says a pre-approval from his health insurer left out some pretty important information, but patients should know there is a crucial step to take between getting pre-approved and getting treatment.

A pre-approval makes insurers and health providers communicate in advance. Theoretically, it's great. Everything gets worked out upfront. But the approval only tells you the treatment is covered. It's the code that tells you what you are likely to pay.

Mike Smith developed a painful wound on his foot. He needed insurance pre-approval before he could begin treatment with a specialist. A letter from UnitedHealthcare laid out every detail.

"I was approved for 25 visits, and the worst-case scenario would have been $25 per visit," Smith said.

The wound care services were listed on the approval letter; as was the code the provider would use on the claims. Smith says during the weekly treatments, the provider cut away dead skin and cleaned and dressed the wound.

"I didn't see it as any big deal. I certainly didn't see it as surgery," Smith said.

But the provider did. The code on the approval letter was for surgery, not an office visit as Smith thought. Instead of $25, his surgery copay is $150 per visit. He says he wasn't notified until after eight treatments. His bill has grown to over $1,300 and is now in collections. Smith says UnitedHealthcare knew the code in advance but never told him his surgery benefits would apply.

"It doesn't tell me that on the letter of approval and the wound center people certainly never told me that," Smith said.

Smith has learned patients should always ask which benefits apply to the code on an approval letter.

"You better find out from your insurance company what that letter of approval actually means," Smith said.

Smith says doctors recently needed to remove his toe but he's received some good news from UnitedHealthcare.

After we brought it to their attention, UnitedHealthcare told CBS 5 News they were making a one-time exception in Smith's case and were taking care of his entire outstanding bill with the provider - over $1,300. UnitedHealthcare also told CBS 5 News they were adding clarifying language to their approval letters. Here is a company statement:

"We are committed to helping members access the care they need, in the right setting, and appreciate Mr. Smith bringing this matter to our attention."

CBS 5 News thanks UnitedHealthcare for taking quick and fair action in this matter and providing assistance to Smith.

Remember, patients are ultimately responsible for knowing which of their benefits apply to a particular treatment. So when you get an approval letter for service, with the code, the provider will use on it, call your insurer and ask which of your benefits the specific code falls under and make sure you confirm what your copay is for that benefit.

Copyright 2017 KPHO/KTVK (KPHO Broadcasting Corporation). All rights reserved.

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