Illegal Billing?

[moburkes]

Yes, I know it is hard to believe lealea. But that is what happened. Whether they intentionally lied, or were just careless in finding out for sure, or if UHC didn't give them the correct information, I don't know. Maybe the doctors had nothing to do with it and in fact UHC mistakenly verified them as participating providers? That would explain why it happened across so many doctors, if UHC does not provide information correctly to providers. If they can't provide it to me, why would they provide it to doctors/labs?

They didn't have to call. They have no obligation under any law to call. No law states that they do. If they did it, (as a courtesy), and were given incorrect information, AND they wrote down the date/time/name/ext of the person that misspoke, then someone MAY be able to be held accountable, but it won't be the doctor's office. If you have the same proof, then you can use that in your favor. If you don't have that, then too bad on you. We've all had to learn the hard way to document everything.

I'm glad that they knocked the bill down. That probably wasn't a hard thing to do, since, the insurance company would have only paid a portion, anyway.

No amount of arguing will change the facts or the requirements of the law. Sorry that this happened to you. Sorry that you learned the hard way. Sorry that you can't pay your bills.

 

[lealea1005]

lealea, one doctor has reduced a bill from $1100 to $375 which as I explained to them was very generous. However, they provided services under false pretenses (as I believe). Whether it was their fault or UHC I don't know. What I do know is that I don't have $375. The person in charge of billing promptly hung up the phone on me despite the fact that I was being very polite and calm throughout the entire conversation.

That's waaay generous! Find a way to pay it, even if they are small payments. Make sure your payments are made EVERY month. If you do not make payments, as I said before, they will take you to court for the payment and will win. The judgement they'll ask for, and will be granted, will be for $1100. Services were not provided under false pretenses, but to the best of their knowledge at the time of service.

 

[cbg]

Wow, I leave for a morning and look what happens!

I can accept that customer service and provider relations are no longer what they were. It's been ten years after all.

However, I cannot get around the fact that the OP expects the provider to determine what procedures are covered and provide the service if it's going to be covered in full (or full minus co-pay). I'm sorry but NO policy is goinig to be written to make that the provider's responsibility. Regardless of what may or may not have happened with regards to who is and is not a network provider (and I agree that it defies belief that each and every doctor and lab either lied or was mistaken about their network status), it is asking FAR too much to expect that they will have either the time or the responsibility to do that. That is NOT their function. It is the responsibility of the insured, not the provider, to know what is covered.

 

[badadjective]

Yes, I understand now why it is my responsibility and not the doctor's office. Unfortunately my insurance company was not able to give me the information and I relied on the doctor's office. Legally I see it's not their fault, but what *******s for telling me they are a participant when they are not. I'm going to pay the bills somehow over time, but I'm definitely going to try to get UHC to cover at least some of the cost.
I think I have enough feedback to move forward. I appreciate all your responses and insight, and will consider this thread closed. Thank you.

 

[lealea1005]

Yes, I understand now why it is my responsibility and not the doctor's office. Unfortunately my insurance company was not able to give me the information and I relied on the doctor's office. Legally I see it's not their fault, but what *******s for telling me they are a participant when they are not. I'm going to pay the bills somehow over time, but I'm definitely going to try to get UHC to cover at least some of the cost.
I think I have enough feedback to move forward. I appreciate all your responses and insight, and will consider this thread closed. Thank you.

Good luck...let us know how it all turns out.

 

[ecmst12]

ecmst-What you are asking for is impossible. If there are hundreds of insurance plans, UHC is not hiring 100 different departments of say 10 or 12 people so that they are staffed properly. Each rep will be able to answer the question for several plans, because, on their computer screen, once you pull up the member number, the information is listed.

Mo, you're definitely wrong about that. How many health insurance companies have you worked for? I've worked for 3, INCLUDING a Medicaid provider. For smaller groups, the HI company will put several together for a department to handle, but for large/high profile groups (and NY state medicaid is most CERTAINLY going to be a huge contract), they will have a dedicated department which will ONLY handle that group. Because the plans are so varied, it makes much more sense to have 20 or 30 or even 50 people (depending on how many members) trained SPECIFICALLY in one plan, or maybe in 3 or 4 plans, and be experts in the plan(s) they service, then to have all customer service for the entire company in one big group, only trained on how to look things up in the computer. You get bad service that way, and wrong answers, and (more important to the bigwigs) longer talk times as the rep struggles to look stuff up and read it off the screen, whereas if they were only handling one plan, they'd be able to answer a lot of questions without even looking anything up. When I worked for Aetna, I ONLY serviced AT&T and Lucent employees. At United I processed claims ONLY for AARP Medicare Supplement plans (there were several variations, but all the same general idea and all the same plan sponsor). The medicaid provider I worked for had many offices/branches, but in that case the entire OFFICE that I worked in was dedicated solely to Delaware Medicaid.

So yes, UHC does in fact have hundreds of different departments for customer service and claims, each specializing in one plan or in a few different (but similar) plans. Big companies like to know that they have one group of people that their employees will talk to every time they call, who are ONLY there for that company. NY state probably even stipulates in their contract with UHC that there will be a dedicated unit handling their members.

 

[moburkes]

My experience has been different. Both of my parents have owned their own small businesses, and have provided health insurance. Depending upon which business, they were small group policies, and the health insurance company did not pay 20 people to service the questions of 3 employees, 10 employees, 60 employees, and, at the largest, my dad probably had about 500-600.

I don't have specific information about Medicaid.

 

[ecmst12]

Small groups, like I said, are usually bundled together with a few other small group plans for claims and customer service. But it's still not going to be the case that calls or claims for one plan are going to be serviced by a different area every time; insurance companies divide employees into teams based on the plans they service. Small businesses are usually not self-funding and the owner will have a set list of plans to choose from (that's what my dad gets) with less options for customization. So your parents' plans would most likely be serviced by a unit that is trained on "small business plan C" or "small business plans A-C", and they would take care of all the calls or claims on those few plans even though it would be through many different employers. The important thing is that each rep/processor doesn't have to know the details of too many different plans at one time, it cuts down on the possibility of errors.

Anyway PM me if you want more info, I think we're probably hijacking now.

Back to my earlier point, there was some definite ball-dropping on the part of UHC if 1) you were not issued a provider directory listing all of the in-network doctors in your area and 2) they were unable to answer specific questions about what doctors were in-network when you called. This does NOT make you less responsible for the bill - you received the services, regardless of whatever unfortunate incorrect information you received, and you have to make sure they get paid. I wouldn't start making payments out of your (not very deep) pockets just yet, the medicaid office and/or department of insurance should be able to help you out, but arguing that there were "false pretenses" when in fact there was just miscommunications/honest mistakes is not going to get you very far. Remember that if phone calls don't work, PUT IT IN WRITING, and send it certified mail, return reciept requested. Save copies of everything. Keep detailed notes, write down what day/time you called and who you spoke to. If they won't let you talk to a supervisor, then get the supervisors name and mailing address and send the letter to them directlyI really think that UHC should take responsibility for their crappy customer service and pay these bills, in network or not, but it might take some pressure for them to do so.