Estimated read time: 3-4 minutes
WEST JORDAN — Imagine being on the hook for a hefty medical bill because your doctor's office fumbled the procedure's prior authorization. That's the situation a West Jordan man said he faced. “I would toss and turn at night,” Michael Mason said of his struggles using a CPAP machine to open up his airway. “Sometimes the mask would end up over here (pointing to the side of his face). Sometimes it would be off when I woke up in the morning.” So, Mason’s doctor found another option, a device called Inspire. “Inspire is a device that will trigger your nerve for your tongue to open the airwaves, to make sure that you sleep at night, so you don't stop breathing,” he explained. After a sleep study, Mason says a doctor determined he was a candidate for the implant. As for his insurance? “They said that there was no prior authorization needed,” he said. He didn't ask for a price tag. "We never discussed it,” Mason said. “I thought just based on having insurance that I was good to go.” Apparently not. Months after the surgery, the bill arrived. “It says I owe $25,141.91!” That’s money Mason thinks he shouldn’t have to pay. But when his calls to the doctor, the surgery center, and the insurance company got him nowhere, he asked me to investigate.“I don’t feel that this should be hanging over my head.”
No prior authorization needed
The exact words, “…does not require preauthorization…” come up when we looked up the procedure code on the website for Mason’s insurance company, EMI Health. What does “does not require preauthorization” mean to you? Well, EMI Health says it doesn’t automatically mean they’re going to pay. When the KSL Investigators reached out to the insurer, we were told it doesn't mean it'll be covered. In fact, Mason’s health plan simply does not cover the procedure, which is why his claim was denied. The “clunky” language seems to have confused the staff at the Alta View Surgery Center, too. A spokesperson for the center told KSL, “Initially, Mr. Mason's physician and the Surgery Center were told that preauthorization for the procedure was not required.” So, they proceeded. It wasn’t until the device had been implanted “Afterward, Mr. Mason's insurance company informed us that the surgery was not covered under his insurance plan,” the spokesperson wrote. “I got the Inspire device to sleep comfortably,” Mason said. “And now I'm worried about a bill hanging over my head at 26 grand.”
Avoiding costly mix-ups
It's not hanging over his head anymore. After reviewing it all, the surgery center tells KSL they've decided it's not right for Mason to be hit with, what they called, “a large, unexpected burden.” Instead, they chose to cover the cost of what his insurance would have paid for his surgery. Mason’s experience highlights something many patients might not realize: Just because a procedure doesn't require preauthorization is no guarantee that it’s actually covered by your insurance. So, before any non-emergency surgery, experts recommend doing three quick things: Ask the doctor's office to verify coverage. Call your insurance company yourself. And get confirmation in writing if possible.
Read more: Pre-Authorization confusion leaves Utah man with $80,000 in medical bills
