Aetna Says Doctor Made Billing Error, But The Patient Is The One Who Owes $6K For MRI

The wonderful world of medical billing, where not up is down, left is right, and the patient is somehow the one left with a hefty bill if their surgeon screws up on the paperwork.

The L.A. Times David Lazarus has the story of a California man whose teen daughter tore her anterior cruciate ligament while playing volleyball. After consulting with some doctors and getting an MRI, his daughter had surgery — approved by Aetna — to repair the ACL.

All seemed fine until the dad received a $6,000 bill for an MRI that had been performed before the surgery. The insurance company said he was responsible for the cost because the surgeon hadn’t gotten proper pre-approval for the scan.

And the hospital said he’d signed a waiver agreeing to pay any bills the insurer refused to pay.

The dad argued — and several surgeons agreed — that the MRI was part of the surgery and that no surgeon would have performed the surgeon without one.

His attempt to EECB the top brass at Aetna went without a reply. But when Lazarus got involved, Aetna suddenly labeled the whole thing a “misunderstanding.”

“This sort of thing shouldn’t happen,” says a company rep. “We definitely don’t want the patient getting caught in the middle.”

So why don’t they listen to the patient when they do get caught in the middle (unless they happen to get major print media involved)?

The rep says that the doctor — and not the patient — is actually responsible for the error, but that a coding error is responsible for the letter from Aetna saying the patient was on the hook for the $6,000.

In the end — and again, only because a high-profile L.A. Times columnist got involved — Aetna decided to pay for the MRI and scold the doctor for not seeking the proper pre-approval for the procedure.

According to the American Medical Association, nearly one of out every five insurance claims are processed incorrectly by health insurers. We’re having trouble thinking of a job — outside of Major League Baseball — where a 20% failure rate is considered acceptable.

A sports injury leads to a big foul in medical billing [L.A. Times]