Pre-approved, paid, now UHC wants $$ back

[khchiro]

What is the name of your state (only U.S. law)? Texas

I am a health care provider in-network with UHC. I preapprove all my visits b/c otherwise they will not pay. In March 2010, I received a notice from a company called J&P, contracted by a company called OptumHealth, contracted by UHC to get a refund for 22 patient visits that had been pre-approved and paid. I sent my notes and appealed and they say the treatment is not 'medically necessary' but they refuse to explain what it is my noted are missing that renders the treatment unnecessary.

I keep notes according to what I was taught and what I learn in my yearly continuing education classes. I take my job very seriously. I don't appreciate being treated as a shyster by someone subcontracted by a subcontractor solely to bilk money out of me. Every time I contact J&P, UHC or OptumHealth about this, I get a different answer and the amount they want keeps going up!

I do not want to have to call patients and say they owe hundreds of dollars for visits paid for over a year ago. I seriously doubt they would pay anyway. I have filed three complaints with Texas Dept of Insurance, but they refuse to comment on cases of 'medical necessity' nor will they address the way this whole thing is being handled. Is there anything I can do or is this just another way they slowly kill my soul and drain my bank account?

 

[lealea1005]

What is the name of your state (only U.S. law)? Texas

I am a health care provider in-network with UHC. I preapprove all my visits b/c otherwise they will not pay. In March 2010, I received a notice from a company called J&P, contracted by a company called OptumHealth, contracted by UHC to get a refund for 22 patient visits that had been pre-approved and paid. I sent my notes and appealed and they say the treatment is not 'medically necessary' but they refuse to explain what it is my noted are missing that renders the treatment unnecessary.

I keep notes according to what I was taught and what I learn in my yearly continuing education classes. I take my job very seriously. I don't appreciate being treated as a shyster by someone subcontracted by a subcontractor solely to bilk money out of me. Every time I contact J&P, UHC or OptumHealth about this, I get a different answer and the amount they want keeps going up!

I do not want to have to call patients and say they owe hundreds of dollars for visits paid for over a year ago. I seriously doubt they would pay anyway. I have filed three complaints with Texas Dept of Insurance, but they refuse to comment on cases of 'medical necessity' nor will they address the way this whole thing is being handled. Is there anything I can do or is this just another way they slowly kill my soul and drain my bank account?

This happens more often than you would think. UHC must have conducted an internal audit and changed their decision (I believe they have up to 2 years to do so). The patients have received updated EOBs from UHC indicating the change and their responsibily for payment. Unless there is some contractural reason you cannot collect, bill the patients. You rendered services and deserve to be paid for your time.

I assume you have patients fill out a registration form and sign something stating they are ultimately responsible for payment if their insurance company denies or does not cover the service.

 

[Betty]

I agree, bill the patients. They are ultimately responsible for anything that
ins. doesn't pay.