UHC (united) billing weirdness and lagging on approval...
I don't know if this is happening to anyone else with United Healthcare but they're really ticking me off lately. The insurance coordinator at my surgeons office told me their rep said all the pre-op tests were covered under my plan.... yet I got a bill for about $1200 of tests they completely did not cover... WTF. And my paperwork was all submitted about 3.5 weeks ago and still no response. I've seen some people on the boards talk about UHC having a quick response and being easy to work with, so this is a bit frustrating.
Is anyone else having similar issues with UHC lately?
Is anyone else having similar issues with UHC lately?
Without knowing the specifics of your plan it is hard to figure out what is going on. Do you have a deductible that needs to be met? what is your cost-share? UHC usually processes my claims within 48 hours. I would suggest looking at your EOBs (Explanation of Benefits), you can access them online, and see where the amount you owe is coming from. There is also the possibility that the insurance company wasn't billed correctly. Then take a look at your coverage, if you disagree with the way they have applied any of the billing/payments, then appeal. I know I have a deductible of $1250 so I was responsible for some of my pre-op testing.
As for your approval, call UHC. 3.5 weeks is a long time for them. Its possible that something is missing and they have contacted your surgeon (either via phone or in writing). However, you will not know unless you call them and ask.
As for your approval, call UHC. 3.5 weeks is a long time for them. Its possible that something is missing and they have contacted your surgeon (either via phone or in writing). However, you will not know unless you call them and ask.
Top is my progress, Bottom is to Surgeon's Goal
I have UHC EPO (no deductible and my plan is supposed to cover everything the PPO does as long as i'm in-network, with a copay of $10 per visit for most everything)... I spent a few hours playing phone tag today and was told:
1) my surgery is still pending decision. the medical director has it (not sure if that's normal?). my surgeons office as of this morning said they hadn't heard anything back. this submission was after the first one was closed and had to be re-opened because the UHC adjuster was being super impatient about getting the paperwork completed within 24 hours.. (my surgeons office was missing one year of weights and UHC wouldnt wait an extra day to get it faxed over)
2) although they insisted i do 6 nutrition visits and in the course of the same conversation said all pre-op visits would be covered under my plan, they are now deciding to only pay for 2 of them and now say my plan only covers 3 nutrition visits per lifetime per diagnosis... and they counted my intro bariatric class as another visit. WTF.
3) the two main radiology tests they denied (for no noted reason) - upper GI and chest xray - they told me should be covered and the doctors are in-network YET they still wouldn't fix it for me on the phone. they said they'll put it "under review" and i should know IF they fix it in 10 biz days.... double-WTF.
4) the psych eval (done a month ago, still no reimbursement) i have to deal with another UHC phone bank to make sure they cover, since i was explicitly told before making the appt by a UHC rep that it would indeed be covered.
big hassle. all of that, plus just the last few months of copays for visits, tests and such = $1500. that doesn't count the meds UHC won't cover (heavy duty iron and vit D) and prior months of copays re: surgery. i'm not made of money and my plan is supposed to cover most costs, so this is super annoying. i hope it all gets resolved soon.
1) my surgery is still pending decision. the medical director has it (not sure if that's normal?). my surgeons office as of this morning said they hadn't heard anything back. this submission was after the first one was closed and had to be re-opened because the UHC adjuster was being super impatient about getting the paperwork completed within 24 hours.. (my surgeons office was missing one year of weights and UHC wouldnt wait an extra day to get it faxed over)
2) although they insisted i do 6 nutrition visits and in the course of the same conversation said all pre-op visits would be covered under my plan, they are now deciding to only pay for 2 of them and now say my plan only covers 3 nutrition visits per lifetime per diagnosis... and they counted my intro bariatric class as another visit. WTF.
3) the two main radiology tests they denied (for no noted reason) - upper GI and chest xray - they told me should be covered and the doctors are in-network YET they still wouldn't fix it for me on the phone. they said they'll put it "under review" and i should know IF they fix it in 10 biz days.... double-WTF.
4) the psych eval (done a month ago, still no reimbursement) i have to deal with another UHC phone bank to make sure they cover, since i was explicitly told before making the appt by a UHC rep that it would indeed be covered.
big hassle. all of that, plus just the last few months of copays for visits, tests and such = $1500. that doesn't count the meds UHC won't cover (heavy duty iron and vit D) and prior months of copays re: surgery. i'm not made of money and my plan is supposed to cover most costs, so this is super annoying. i hope it all gets resolved soon.
I definately understand your frustration.
1. Since the file is with the medical director, call UHC and tell them that you would like to speak to someone in the Medical Director's office. DO NOT TAKE NO FOR AN ANSWER. (However, you may have to agree to a call back for this). Once you get to the office, explain to them that your file has been with UHC for 3.5 weeks and you would like to know when you can expect a decision. The fact that it is with a medical director is not necessarily a bad thing.
2. Pull a copy of your policy. (If you dont have one, you can get it from your employer. The law requires that you be able to obtain a copy) Does your policy limit the nutrition visits? if it doesn't specifically say anything, then APPEAL and reference your policy. Even if it does limit them, appeal but then reference the fact that the nutrition classes are their prerequestite for WLS. As for being told that "all pre-op visits would be covered", some insurance plans does not consider nutrition plans to be a pre-op visit since you are usually not meeting with a physician or a PA. (Yes this is stupid)
3. APPEAL the radiology tests. Most companies do require their appeals in writing. In this appeal, cite your policy. It will strengthen your case.
4. My psych eval took 4 weeks to pay. As long as your are sure that it was billed, you need to wait to see if they pay. While you are waiting, look at your policy and see if there is an exclusion for mental health. If their isn't, you have an appeal if they do deny.
I know that having to appeal is a hassle and they do tend to take about 30 days. However, it is much better than having to come out of pocket for costs that should be paid. I hope it all resolves quickly and that you have your approval.
GOOD LUCK!!!
1. Since the file is with the medical director, call UHC and tell them that you would like to speak to someone in the Medical Director's office. DO NOT TAKE NO FOR AN ANSWER. (However, you may have to agree to a call back for this). Once you get to the office, explain to them that your file has been with UHC for 3.5 weeks and you would like to know when you can expect a decision. The fact that it is with a medical director is not necessarily a bad thing.
2. Pull a copy of your policy. (If you dont have one, you can get it from your employer. The law requires that you be able to obtain a copy) Does your policy limit the nutrition visits? if it doesn't specifically say anything, then APPEAL and reference your policy. Even if it does limit them, appeal but then reference the fact that the nutrition classes are their prerequestite for WLS. As for being told that "all pre-op visits would be covered", some insurance plans does not consider nutrition plans to be a pre-op visit since you are usually not meeting with a physician or a PA. (Yes this is stupid)
3. APPEAL the radiology tests. Most companies do require their appeals in writing. In this appeal, cite your policy. It will strengthen your case.
4. My psych eval took 4 weeks to pay. As long as your are sure that it was billed, you need to wait to see if they pay. While you are waiting, look at your policy and see if there is an exclusion for mental health. If their isn't, you have an appeal if they do deny.
I know that having to appeal is a hassle and they do tend to take about 30 days. However, it is much better than having to come out of pocket for costs that should be paid. I hope it all resolves quickly and that you have your approval.
GOOD LUCK!!!
Top is my progress, Bottom is to Surgeon's Goal
thanks for your super detailed and thoughtful reply! 
the latest news is that they sent a denial to my surgeon this morning. my surgeon got on the phone w/the medical director and had a peer review. turns out the denial was because UHC overlooked some paperwork that they already had and tried to deny me for not sending it in. nice. so according to my surgeon's office, they're going to overturn it and approve by next week. i'll believe it when i see it, at this point.
as for the rest -- i'm definitely going to appeal it ALL if they don't fix the billing mistakes. i can't afford the added expense right now, plus it's just lame for them to think they can rip people off.
the latest news is that they sent a denial to my surgeon this morning. my surgeon got on the phone w/the medical director and had a peer review. turns out the denial was because UHC overlooked some paperwork that they already had and tried to deny me for not sending it in. nice. so according to my surgeon's office, they're going to overturn it and approve by next week. i'll believe it when i see it, at this point.
as for the rest -- i'm definitely going to appeal it ALL if they don't fix the billing mistakes. i can't afford the added expense right now, plus it's just lame for them to think they can rip people off.
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