MILWAUKEE — Jeff Magnuson looks like a healthy guy. But for about a year, he's been receiving cancer treatment. He's recovering from Stage 3 melanoma.
"There was a mole that was approximately right there," said Magnuson as he showed the scar from surgery on his calf.
A scar that's now a reminder of the $41,337.60 bill his medical provider, Aurora Health Care, charged and his insurance, Anthem, didn't want to cover.
"The surgery to identify the lymph node, the sentinel node, which ultimately had the cancer cells, which raised it from a Stage 2 cancer to a Stage 3 cancer, was not medically necessary," Magnuson explained.
Magnuson said it was "extremely shocking."
He explained he has been receiving immunotherapy to treat cancer. But at the same time, Magnuson has been trying to get the procedure that identified his Stage 3 cancer covered by his insurance.
Magnuson appealed Anthem's decision twice and each time, he said he received a little more of an explanation as to why it wasn't being covered.
"The closure of the wound was listed as a complex closure, but based on what the insurance company could see, it was a simple closure," Magnuson said.
"That means nothing to me before and it means nothing to me now," he continued.
"I had a wound on my leg and they needed to close it," he said.
WTMJ reached out to medical billing expert Pat Willis, asking her how common it was for an insurance company and medical provider to disagree on whether a surgery is complex or simple.
"No. It's not common," Willis said.
When Willis reviewed the medical coding used in Magnuson's case, she discovered something.
"There's no such thing as an 'intermediate complex' code. There is no such thing. Whoever wrote 'intermediate complex,' that does not exist. It's either 'intermediate' or it's 'complex.' It's not both,” Willis continued.
The wording of the coding, according to Willis, was incorrect.
WTMJ asked Aurora and Anthem in late August to answer our questions about this case.
On September 28, an Aurora spokesperson said:
"Our top priority is to provide the highest quality care for those we serve. That includes helping our patients navigate issues related to billing and insurance, which we know can be complex. Federal and state laws prohibit us from commenting further on specific cases."
Anthem's spokesperson provided the following statement:
Anthem’s team has been working closely with Aurora to resolve this case for Mr. Magnuson. Aurora will resubmit the claim without the SPECT scan and Anthem will cover the non-SPECT services per the terms of Mr. Magnuson’s health plan. Aurora has agreed to write off the charge for the SPECT scan itself, meaning that Mr. Magnuson will not be charged for that service.
On September 30, Magnuson said he received a call. Aurora and Anthem reached an agreement and he doesn't have to pay a dime.
"It's a huge weight off of my shoulders after I've been dealing with this since I first got the bill in October," Magnuson said.
"I appreciate everything that you guys have done and that TMJ4 (WTMJ) has done in helping me, or us, get to the bottom of this, helping get this claim taken care of, so I can focus on my treatment and getting healthy,” he continued.
If you are struggling with a medical bill, here’s what you can do:
1. Willis suggests asking that your medical bill be itemized with what’s called CPT codes (this explains to the insurance company how a doctor billed their services).
2. If your insurance won't cover the bill, ask your doctor to write a letter to the insurance company, saying the procedure was medically necessary.
3. Consider writing a letter to the Chief Financial Officer of your insurance or medical provider.
4. While this all of this is happening, ask your provider to put the bill on hold so it's not sent to collections.