A sports injury leads to a big foul in medical billing

It’s amazing how easily the smallest healthcare mix-up can spin out of control and leave the patient on the hook for thousands of dollars in medical bills.

In Jim Furlan’s case, his journey into the healthcare Twilight Zone began in September when his then-15-year-old daughter injured her knee playing in a volleyball tournament in Las Vegas.

“She was rushed to the hospital in extreme pain,” he recalled the other day. “They had to give her morphine.”

The girl then flew home to Manhattan Beach, where her doctor ordered an MRI at Torrance Memorial Medical Center. It showed that she’d torn her anterior cruciate ligament, or ACL, a serious but not uncommon sports injury.

The next day, Furlan sought a second opinion from a prominent orthopedic surgeon, who confirmed the diagnosis. He scheduled an operation for about a week later, which Furlan’s insurer, Aetna, readily approved.

So far so good.

The trouble began after the procedure was successfully completed. Furlan received a letter from Aetna saying that because the MRI hadn’t been preapproved, he’d have to pay the nearly $6,000 cost himself.

Furlan appealed the decision. “They approved the surgery,” he told me, “and no doctor would perform this surgery without first doing an MRI.”

It’s a fair point. I spoke with several orthopedic surgeons, and each said that in the case of knee injuries, it’s almost always prudent to perform an MRI before breaking out the scalpel.

“The MRI can show if there’s other damage,” said Dr. Richard Bowen at Los Angeles Orthopaedic Hospital. “The vast majority of doctors would do an MRI before treatment.”

Dr. David McAllister, director of UCLA’s sports medicine program, observed that if additional problems were found while a patient was under anesthesia, a surgeon wouldn’t be able to fix them because no prior approval had been given.

“That’s a big reason why an MRI makes sense,” he said. “Otherwise, the patient would have to come in for a second surgery, which would be much more expensive for the insurer.”

But Aetna stuck to its guns. It denied Furlan’s appeal on the grounds that “precertification was required for the MRI and there is none on file.”

Never mind that if the insurer’s bean counters had stopped to think about things for just a moment, they’d probably have agreed with the medical experts that an MRI is a key part of ACL surgery.

Meanwhile, Torrance Memorial Medical Center started billing Furlan because he’d signed a waiver declaring that if his insurer didn’t pony up, he’d have to cover the tab. The hospital’s invoices warned that if he didn’t make good, “your account will be referred to a professional collection agency.”

Frustrated, Furlan took his case straight to the top, writing a letter last month to Aetna’s chief executive, Mark Bertolini. He said he received no answer. So he came to me.

An Aetna spokeswoman, Cynthia Michener, deemed the whole mess “a big misunderstanding.”

She said Furlan’s doctor erred in not seeking pre-approval for the MRI, so as far as Aetna was concerned, the doctor, not Furlan, was responsible for the nearly $6,000 bill.

But that’s not what the insurer’s letters to Furlan say. They say “you are responsible” for the MRI costs. Michener blamed that language on “an incorrect code” somehow being entered on Furlan’s file.

As Furlan saw things, he’d have to pay the thousands of dollars to Torrance Memorial and then sue his doctor for reimbursement — a crazy turn of events.

Aetna’s Michener agreed. “This sort of thing shouldn’t happen,” she said. “We definitely don’t want the patient getting caught in the middle.”

Yet this sort of thing does happen, and with alarming frequency. One of the many shortcomings of the U.S. healthcare system is that, with so many players vying for people’s money, and with so much clerical bureaucracy baked into billing, it’s often difficult to simply get one party to speak with another.

And before you know it, minor misunderstandings escalate to collection agencies and lawsuits.

At least Aetna has decided to do the stand-up thing. Michener said the insurer would cover Furlan’s MRI bill and school Furlan’s doctor on the importance of getting pre-approval for tests.

That’s great. But you’d think Aetna could have made this decision sooner, such as during the appeal process (and before the news media started sniffing around).

The U.S. healthcare industry is worth about $3 trillion. Would it kill these people to simply pick up the phone and call one another from time to time?

David Lazarus’ column runs Tuesdays and Fridays. He can be seen daily on KTLA-TV. Send your tips or feedback to david.lazarus@latimes.com.