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Get Gephardt helps man stuck with an out-of-network bill for a test his insurance pre-authorized

Dec 6, 2023, 10:49 PM | Updated: Dec 7, 2023, 5:58 am

MORGAN, Morgan County — Prior authorization, pre-approval, prior approval; in the medical insurance world, they mean the same thing. But if it goes wrong, you could be stuck with a hospital bill much more significant than you expected.

A health scare in the family persuaded Robert Bohman to get his ticker checked.

“My brother had an issue with his heart,” Bohman said. “It had a genetic aspect to it.

Bohman’s doctor ordered an echocardiogram, basically an ultrasound of his heart. Now, Bohman’s insurance had to OK the test.

“They gave the authorization letter,” he said.

But after his heart got hit with sound waves, he got hit with a financial shockwave.

“I got billed as if it’s out-of-network,” Bohman said.

Though the prior authorization letter from the insurance says the hospital is in-network, Bohman says it turned out it’s not. He now owes $982, nearly four times the $259 in-network price he expected to pay. Adding to his concern, the hospital is threatening to send him to collections.

“It’s not fair at all. We should not have to go to the doctor’s, and every time we go, we feel like we’re walking through a minefield — a financial minefield,” he said.

After countless hours of trying to clear that minefield without success, Bohman decided to contact the KSL Investigators.

KSL contacted Bohman’s insurance company, Anthem Blue Cross, on his behalf. Bohman has a letter saying he was pre-approved as in-network, so how can they deny payment now? Well, apparently, pre-approval doesn’t mean what Bohman thinks.

By phone, Anthem told us prior authorization “determines if a procedure is medically necessary” but that it “does not guarantee” it will be covered by insurance.

So, where does this all leave Robert?

Well, after our calls, Anthem admitted that the pre-authorization letter may have been confusing, and the plan’s sponsor — the spokesperson told us — has decided to pay that $791 difference between the in-network and out-of-network costs.

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Get Gephardt helps man stuck with an out-of-network bill for a test his insurance pre-authorized