Don't let providers get surgery approvals from your insurer

Posted: Updated:
SUN CITY WEST, AZ (3TV/CBS 5) -

A senior says he's stuck with a huge medical bill because he got confusing information from his health insurer. There is really only one smart way to avoid this type of devastating medical mistake.

Not all treatments are covered under any given health plan. Before you schedule an expensive elective procedure, you need your insurer to confirm it's covered. Make sure it's you, not the medical provider's office, who asks the question and gets the response in writing.

"Do it yourself, don't leave it to anyone else," Lou Kunkin said.

Stricken with cancer, 70+-year-old Kunkin had his prostate completely removed. For years after he says nerve damage from the surgery caused him to struggle with sexual dysfunction.

"We've tried all the different interventions they have, pills, injections, pumps, and nothing was able to work," Kunkin said.

Kunkin's doctor provided a letter stating a very specific sexual dysfunction treatment was medically necessary to correct the problem. Kunkin was in the room at the Mayo Clinic but allowed one of their reps to ask his insurer if the treatment was covered. The Mayo rep said Blue Cross Blue Shield had good news.

"After the procedure, they were going to require the operative report and the letter of medical necessity. The implication was it would then be covered," Kunkin said.

After the procedure, Blue Cross Blue Shield denied the claim saying sexual dysfunction treatments are not covered; regardless of cause. Kunkin has been fighting the decision for two years but to no avail. He's stuck with a $37,000 bill.

"To come up with something like that, I would have to mortgage the house and be responsible for those payments," Kunkin said.

Kunkin says Blue Cross Blue Shield has a different interpretation of what they told Mayo that day on the phone. He's learned it's best to get your own answers.

"Make the phone call yourself. Before you make it, make a list of the questions you're going to ask," Kunkin said.

Write down the answers, document who you spoke to, and most importantly, demand an email confirmation that the procedure is covered. This is the only real way to defend yourself if something like this happens.

At our request, Blue Cross Blue Shield reviewed that phone call with Mayo again. Afterward, Kunkin says BCBS told him the discussion that day was confusing and they had decided to make an exception and cover the claim. Instead of owing nearly $40,000 in total, Kunkin says BCBS told him he has a zero balance. Our thanks to Blue Cross Blue Shield for being fair and doing the right thing to resolve this dispute.

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

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