Eat me, United Healthcare

The BBQ Pit
41

So two things: I was actually coming back to respond to Cemetery Savior who made a good point. It wasn’t just United that acted like dinks when it came to pre-certs. Actually, in my experience, they were some of the more pleasant to deal with. Blue Cross was a completely different and painful story.

But then, in the mail today, I got a fucking letter from Ingenix. They just wanted me to make triply, quadruply sure that I really did break my arm by being my own klutzy self. I’ve lost count of my Ingenix letters, but I know this is at least number 3. And I’m still not going to tell them that someone else broke my arm.

-Lil

42

[QUOTE=percypercy]
So two things: I was actually coming back to respond to Cemetery Savior who made a good point. It wasn’t just United that acted like dinks when it came to pre-certs. Actually, in my experience, they were some of the more pleasant to deal with. Blue Cross was a completely different and painful story.

But then, in the mail today, I got a fucking letter from Ingenix. They just wanted me to make triply, quadruply sure that I really did break my arm by being my own klutzy self. I’ve lost count of my Ingenix letters, but I know this is at least number 3. And I’m still not going to tell them that someone else broke my arm.

-Lil
[/QUOTE]

That’s an accident information letter. In any situation of physical injury, UHC’s fraud/subrogation arm (Ingenix) has to send out a letter asking for details. the idea is that they want to make sure that someone else’s insurance isn’t liable (in the case of an auto accident), or to make sure a lawsuit against the injuring party (in the case of a mugging or something) isn’t useful.

I will tell you that a phone call to the 800# on the back of your ID Card should be able to get rid of this issue.

This all goes back to having to protect the client’s money (on large cases), or UHC’s money (on smaller cases). We need to make sure we’re the ones who are supposed to pay the claim.

I will agree it’s frustrating…try calling your 800#, and see if they can’t update the record.

-Cem

43

[QUOTE=Trunk]
You seem to be of this mindset that doctors are infallible.

Like they just make these scientific decisions that are either right or wrong and they advise patients accurately. Like they’re not susceptible to over-prescribing. Or they don’t make decisions that bring them repeat business. Or they’re immune to the pressure put on them from the drug companies.

I’m (obviously) no fan of insurance companies, but at least insurance companies act as a check on corruption that would be present in doctors and hospitals if left unchecked.

The whole thing is a medical-corporate complex and I think doctors, hospitals, big pharma, or big insurance can equally share the blame.
[/QUOTE]

Well, since my research involves investigating medical errors for a certain condition, I’m going to nip that first statement in the bud. Doctors are not infallible.

Look, if the insurance company thinks something is unnecessary, fine. Get a second opinion if there’s genuine controversy. Medicine is both a science and an art and not all patients can be treated the same. If there’s one thing I’ve learned about biology and medicine - there’s always an exception somewhere. Yes, maybe 98% of patients respond to treatment x, but for 2% they have side effects or something and need something that isn’t standard. Why do we have to spend all this time on the phone if there’s a good reason for deviating from the norm? Hell, I had to make three goddamn phone calls to get approval for the HPV vaccine, and threaten to cancel my service. I was an ideal candidate for the vaccine and I have a strong family history of cervical cancer.

And repeat business? Jesus. That doesn’t even deserve a response, it’s so insane.

44

[QUOTE=Vinyl Turnip]
These sound remarkably similar to almost every experience I have with them, almost every time I go to the doctor for anything. Claims are paid partially or not at all, and it takes months, multiple calls, and faxes to resolve the issue.

It’s to the point where I suspect something more sinister than simple incompetence or bureaucratic entanglement. I’m beginning to think it’s an intentional business model, something akin to the “mail-in rebate” pseudoscam, where companies count on (and ultimately profit from) a large percentage of people not bothering to complete the rebate form, or giving up in frustration when the paperwork gets “lost” and the rebate never arrives, etc. Surely there must be people out there who simply pay the doctor’s bill either because they’re unaware they aren’t responsible for it or are frightened at the prospect of collection notices and marred credit.

I’m not one of those people, but they’ve sure caused me a lot of wasted time and hassle, so yes. They may eat me as well.
[/QUOTE]

They may bite me too. Aetna, I’m looking directly at you. :mad:
7+ months after a couple of sick visits and we’re still waiting on those effers to pay up.
In the meantime I’m getting collection letters from the doctor. Luckily the person handling billing has been really understanding about it, but frankly I’m embarrassed.

We first got rejected because they were pulling up my husband’s old insurance from a job he had quit 4 years ago. Went round for about a month with that until they found his new info in the computer.
Submitted our claim again on the good info and it got rejected again. Why this time? ‘Any time you have an x-ray, they automatically reject it’ is what I was told on the phone by an Aetna employee. You have to fill out an Explanation of Benefits before they’ll consider it and you have to ask for an Explanation of Benefits form before they’ll send you one.
Okaaaaaaay. I get that another insurance might be liable for it, but could you please send out the form with an explanation instead of just saying ‘we’re not paying this, but you might can appeal’? :rolleyes:
So, we get the form, fill it out, fax it back and wait. Then we get another bill from the doctor a month later with no word from the insurance.
Call up Aetna, wait another month, get another rejection letter.
We call them and they claim they didn’t get an Eob, so I fax it again and wait a week. Then I call the insurance company back and get told ‘yes we received your EoB **3 months ago ** but it was never sent back, we’ll do that now’.
And on and on.
Basically we have 3 claims that they need to cover but every time we call they say they’ll get right on it…and then we have to call again.

Aetna’s policy must be ‘Don’t pay for shit unless threatened with bodily harm’. :rolleyes:

Oh! And the best part on all this calling? One person would give me info on my claim, then the next would tell me I had no right to call on my claim - my husband is the main policy holder so he has to call back on all the claims and he’ll have to sign a release if I was going to be calling for any claims, mine or his.
So he calls to find out about my claim to be told that only I can call about my own claims and if he wants info I’ll have to sign a release for him.
We went back and forth on this; sometimes they’d talk to me on just my stuff, then not at all, then they’re telling me everything.

Frankly after this, my insurance will be money saved in a sock. We have honestly spent more paying for the insurance than the little bit we’re trying to get them to cover like they’re supposed to. :rolleyes:

45

harmless, while you’re waiting for your insurance to pay, ask the gals in the business office at your doctor’s office what minimum monthly payment you can make to keep your account current and out of collections. When it took right on a year for my insurance to finally pay for a surgery, I was able to make $15.00/month payments on my *$30,000 * bill in order to keep it from going to collections. (Boy, I laughed and laughed when that came in the mail.) Then, when the insurance finally paid, my doc’s office refunded me that money.

(BTW, I may have posted this before, but I had a breast reduction with all its required pre-certifications and okee-dokees from the insurance company. Then they didn’t pay and didn’t pay. I’d call the insurance company and they blamed it on the docs office. I’d call the docs office and they’d blame the insurance company. I offered to conference call them both together so they could work it out but they would not. I play this game for months. Finally, I get my Benefits Administrator involved and she calls the IC. Here’s the deal, a breast reduction is considered to be two surgeries - one on each breast. The IC said that the reason they didn’t pay is that the docs office would submit the claim as three surgeries. IOW, just throwin’ shit to see if something would stick, they’d code it as a single surgery, and also two seperate surgeries. As BCBS doesn’t cover reductions for a woman with three breasts, they denied it. Over and over. In the end, my surgeon sucked ass and I had to have the whole thing redone. She had the balls to tell me that she was hesitant to do my surgery again since my insurance co. was so slow to pay! Look, bitch, I wouldn’t even HAVE to do this surgery again if you’d done it right the first time! But I’ll save that for the “My Plastic Surgeon SUCKS ASS” Pit thread. )

46

[QUOTE=Thru the Blue]
And repeat business? Jesus. That doesn’t even deserve a response, it’s so insane.
[/QUOTE]

Yeah, right.

Keep going to see your dentist every 6 months.

Keep going to your doctor for that yearly physical.

Have your knee surgery, and go visit your doctor once a month for six months.

Take this prescription to clear up that infection, and come back and see me in a month whether you feel fine or not.

Stay off the bike for a couple weeks, then come back to see me whether it’s still inflamed or not.

All just insane.

I’d hate to bust up your idol worship, though. Everything doctors say is just exactly what is needed for proper treatment, and nothing more. Pure healers, that lot, doing it solely out of the kindness of their hearts.

47

I’ll ask it here, since people have an interest…

As I’m an Operations Manager at a large Health Insurer (UHC), I coudl open up a “Ask the Insurance Operations Guy” thread.

I’d try to answer questions about the general operations within claims payment, what some letters might mean, and answer thw "Why"s.

Do you all think that might be a good idea?

-Cem

48

Cemetery Savior I have two questions:

-Does your company have a formal or informal policy of routinely denying medical claims with the stated or implied purpose of reducing monies paid out by your company?

-How often do these many qualified doctors and/or RNs on your company’s payroll go to the hospital or doctor’s office to see if what has been submitted is required?

49

[QUOTE=Sean Factotum]
Cemetery Savior I have two questions:

-Does your company have a formal or informal policy of routinely denying medical claims with the stated or implied purpose of reducing monies paid out by your company?

-How often do these many qualified doctors and/or RNs on your company’s payroll go to the hospital or doctor’s office to see if what has been submitted is required?
[/QUOTE]

[ol]
[li]There is no policy, formal or otherwise, designed to limit claim payouts on medically necessary procedures. The only time we’ll deny claims is if there’s a coding issue (the procedure doesn’t match the diagnosis), we need more information (like accident details, other insurance details), or if the procedure is excluded by the contract (bariatric sx for most contracts, cosmetic, etc.).[/li][li]I doubt that any docs or RNs ever go personally to a facility or provider to view a member’s situation. The volume would be immense. I do know that RNs in our Notification/Pre-Cert area discuss member situations as the main part of their job. This involves determining medical necessity, managing post-release care, and directing members to appropriate post-release care providers (Phys therapy, Occ Therapy, Rehab, etc.). Doctors handle escalated “peer-to-peer” reviews where they speak directly to the member’s physician to help determine appeal status and medical necessity.[/li][/ol]

We actually interface with the member and member’s physicians fairly often.

-Cem

50

Thank you for number 1.

As for the second, there is absolutely no case which would warrant a visit by the folks who, let’s face it, can delay medical treatment because of a perceived error? How is that possible?

51

[QUOTE=Sean Factotum]
Thank you for number 1.

As for the second, there is absolutely no case which would warrant a visit by the folks who, let’s face it, can delay medical treatment because of a perceived error? How is that possible?
[/QUOTE]

I think it’s a question of potential volume and setting precedent. We process about 1 billion claims per year. If I’m charitable and say that the number requiring review are 5%, then we’re at 5 million site visits. That’s not doable.

If you’re talking about a truly rare situation (hemophiliac with transplant needs?), it may warrant a site visit, but I’ve never heard of one.

Or am I missing your question entirely?

-Cem

52

No, I think we’re both talking about the same thing here.

53

[QUOTE=Trunk]
Yeah, right.

Keep going to see your dentist every 6 months.
[/QUOTE]

Preventative care. No one is making you do it.

Also preventative care. I haven’t been in years and no one’s tracked me down yet.

After reviewing hundreds of charts, standard of care appears to be one or two visits a couple months after surgery. Presumably to make sure it’s healed okay and hasn’t gotten infected. I don’t know what kind of dumbass doctor you go to, but that seems a little over the top. All bets are off if you’re having some kind of surgical complication, I would that’s obvious, but apparently you’re a moron.

You know, I doubt anyone would care if you canceled the appointment when you felt better. If you didn’t feel better, ta da! you can go in and bitch them out.

Uhm, yes. You are insane. You would rather they jump straight to surgery for your inflamed knee? From past tendonitis I’ve had, the standard of care appears to be rest and ice it. Maybe some NSAIDS. Frankly, I’d rather have my doc look at non-surgical options first. If your theory was really true, they’d be chomping at the bit to operate and earn the big bucks.

Honestly, what the hell is your problem?

I think that insurance companies should get physician approval before canceling prescriptions, seemingly at random, and apparently I’m advocating that doctors can do whatever they want, whenever they want? I don’t think it’s particularly unreasonable to want expert moderation (ie. a second opinion) if the insurance company and the ordering physician disagree. If the insurance company persists in denying care, then they are practicing medicine and I feel that’s inappropriate.

54

[QUOTE=Cemetery Savior]
[…I doubt that any docs or RNs ever go personally to a facility or provider to view a member’s situation. …
[/QUOTE]

Actually, I have an anecdote which contradicts this. When Moon Unit was born - 10 years ago - I had a c-section. I had verified beforehand that my insurance allowed 4 days in the hospital after a c-section. I probably could have gone home after 3 because, well, she was staying in the hospital and it wasn’t like I’d have to deal with caring for her and my recovery was going decently. But I opted to stay that extra night since it was allowed and it meant I could be closer to the kid.

When I discussed this with the doctor, she said to be darned sure my coverage allowed 4 nights. See, the major insurers sent nurses to review the files of patients each night and they could, theoretically, decide “nope, they should have sent her home today, I don’t care if she’s still here, we won’t pay for it”. Admittedly, this was a group thing, not a specific patient, but they could basically deny things after the expense had been incurred.

A slight hijack: I have dental coverage. Sort of. Doesn’t pay a hell of a lot of the care. And there’s a policy decision that means any analgesia beyond novocaine is simply not covered. No exceptions for patients who cannot get pain relief any other way (I’m a good example of someone for whom novocaine does not work well). I guess they’d rather patients delay treatment indefinitely due to fear of pain, because I know from personal experience that an extraction is a LOT cheaper than a crown or a root canal.

55

[QUOTE=Mama Zappa]
Actually, I have an anecdote which contradicts this. When Moon Unit was born - 10 years ago - I had a c-section. I had verified beforehand that my insurance allowed 4 days in the hospital after a c-section. I probably could have gone home after 3 because, well, she was staying in the hospital and it wasn’t like I’d have to deal with caring for her and my recovery was going decently. But I opted to stay that extra night since it was allowed and it meant I could be closer to the kid.
[/QUOTE]

Oh yes! When I was in for Boglette #1, and had my c-section, she hadn’t gained enough weight to be able to leave. They wanted her to stay an extra day and wanted me to go home! There was no bloody way I was going home without her! I was so shocked (I didn’t know such a thing could happen!) and hurt and scared and… insert hormone ridden anxst here that when the doctor came in, saw me bawling in the corner and asked why (I’m normally rather good at handling things), he said he’d make sure I got to stay the extra day. I didn’t have any problems with them paying for that! This was the same company that had said my c-section wasn’t performed in a legit place, but turned out to be a billing number error.

56

[QUOTE=niblet_head]
As BCBS doesn’t cover reductions for a woman with three breasts, they denied it.
[/QUOTE]
I’d just like to point out that it is possible for a woman to be born with 3 breasts (rare, to be sure) and that if she wanted to have two reduced and the third removed, it looks like she’d be SOL if she had BCBS. (At least until she called a good lawyer.)

57

You. are. kidding. Who knew?

58

[QUOTE=niblet_head]
You. are. kidding. Who knew?
[/QUOTE]

IIRC, one of our Doper’s was born with a 50% bonus in the chest region and had it removed.

59

I was at my doctor’s yesterday, and noticed for the first time a big bright yellow sign taped up on the outside door:

“WE DO NOT TAKE UNITED HEALTHCARE!”

Normally I would probably not have noticed it, but I had just read this thread, so the sign jumped out at me.

60

[QUOTE=teela brown]
I was at my doctor’s yesterday, and noticed for the first time a big bright yellow sign taped up on the outside door:

“WE DO NOT TAKE UNITED HEALTHCARE!”

Normally I would probably not have noticed it, but I had just read this thread, so the sign jumped out at me.
[/QUOTE]

I see from your signature that you’re from the CA-area, no?

Funny thing going on in CA with UHC. Recently (early 2005?), we purchased a large health company in California…Pacificare Health Systems. As the purchaser, we’ve been trying to re-contract their “old” physicians into our networks.

In a CA-based peculiarity, many of these doctors believe that they have a contractual right to maintain an out-of-network Tax ID number in addition to having their UHC in-network TIN numbers. We’re in the process of cracking down on this. Our contracts state that we determine network status on a name basis, and NOT a location basis.

Also, it may have been Quest Diagnostics, which has an in-house lab at many facilities. We recently went through an acrimonius split with them, as we chose another national Lab provider to be our “In-Network” national Lab.

In regards to the breast issue…we would typically allow the removal of the 3rd breast if a doctor determined it to be medically necessary. The other two breasts w/r/t reduction…they’d have to meet our clinical standards for this process (shoulder excoriation from bra straps, back pain, etc.).

-Cem