Do I have any chance of getting United Healthcare to pay an emergency room claim in full?

Question

I'm covered by United Heathcare (UHC). I recently took my son to St Mary's (Bon Secours) Emergency Room in Richmond, VA.

St Mary's is a United in-network hospital, but apparently the emergency room doctor isn't in-network. United only paid some of the bill claimed the remained isn't usual and customary. My in-network and out-of network plan reimbursement rates are identical.

After a few months of talking to folks on the phone, I've filed a formal claim appeal. Do I have any chance of getting the claim paid?

Also, after reviewing the doctor's online, it appears that hardly any doctor at Bon Secours St Marys accepts United. I'd shop for a different hospital if you have the bad luck to be covered by United Healthcare.

Answer 1

The only thing I can say about United when you have a problem is good luck. Something that will sometimes work is send letters with all appropriate documentation to everyone you can think of. IE. the customer service rep, their boss, your agent, the ceo of united, VP's of whatever. They are actually pretty easy to find. Get names off their website. Good luck.

Answer 2

Obviously your plan pays UCR for out of network. It may help your appeal, if you can present an indication to UHC that other ER physicians in the same area charge a similiar amount for the exact same codes. If the charge wasn't reasonable then approach the office that billed you for the doctor.
If you are having difficulty financially, you may want to approach the hospital social worker for any relief they may know about, and, also, you should certainly mention this to UHC - it can't hurt.

Also note the following from the AMA website
"American Medical Association v. United Healthcare (S.D.N.Y.)

The case: This class action lawsuit questions whether United Healthcare (UHC) properly calculates "usual, customary, and reasonable" (UCR) charges when paying physicians or reimbursing patients for medical services. The plaintiffs have substantial evidence that either the UHC database is flawed or that UHC does not systematically follow that database when making payments. Since UHC refuses to disclose its database publicly, this lawsuit is the only apparent way to ascertain whether the UHC database accurately reflects UCR charges."

On CNN; "After the fact, patients should question both insurers and providers if there is a significant discrepancy between the cost of the service and the amount that is covered. Sherry recommends taking the diagnostic code for the procedure and calling other providers to get a sense of what the customary charge is for your area. If you think you have a case, appeal first to the insurer, then to the state department of insurance."

Also check out the "Treatment Cost Estimator" on the myuhc.com site to see what UHC thinks they should allow as UCR in your area for each billing code

Answer 3

United Healthcare Er Coverage

Answer 4

I used to have UHC and they certainly are a pain in the well known to deal with-that's why so many doctors and hospitals won't accept UHC. Anyway, I ran into a similar problem with a claim for my husband. I kept writing them letters, explaining that the procedure was medically necessary and there were no in-network doctors that were available to do the procedure. Their big beef with the claim was that it should have been pre-approved before proceeding. In your case, though, pre-approval wasn't an option-you went into an emergency room and didn't have the time or resources to start calling to see which ER accepted UHC.

So, the long and short of it is keep complaining. The key is to make clear to them that since this was an emergency, you had no choice but to deal with out of network healthcare providers.

BTW, UHC did eventually pay my claim, but it took several letters to do it.

Answer 5

I think Pete W is in the minority here, but I'm glad that there is 1 person that UHC has treated well.

I had the same thing with them.... ER visit to an in-network hospital, doc was not in-net..... after several letters (I had them saved on my computer, changed the date and sent them out weekly... marked 2nd request, 3rd request, 4th request... you get the idea....) explaining that "Unless you hang a sign on the door of the hospital announcing that the doctors in this facility are not in-network,,,, my book, furnished by YOUR company, indicates that this facility is "in-network"... duke it out within the contract(s) you have with your doctors. I am not a party to those contracts. We are furnished with a list of Primary Care docs, so we can control who we establish care with, however in an emergent situation it is not possible to take names of the doctors of the emergency room and review your literature. Additionally, ER docs are usually part of a group of doctors that have usually made the decision NOT to accept UHC for the very reason this letter addresses... non-payment of services."

It only took 9 letters and they paid everything in full.

Best of luck.

Answer 6

Absolutely! Its quite common for an insurance company to be able to pay this type of service in full. You have no control over the doctor you see. The policy and process you have to go through to have this type of claim paid @ the billed charge amount varies from one insurance company to the next... Some will automatically pay the balance with a simple phone call; while others force you to go through the formal appeal process. Your odds are good. So, sit tight and let the process the appeal. Good luck.

Answer 7

Are you being billed for any portion of this visit? Sometimes insurance companies send Explanation of Benefits (EOBS) that look like you have a balance, but unless you're getting a bill from the provider, you don't owe the money.

Aside from that, if you used an emergency facilty for a true medical emergency (sadly, many people who use ERs don't have true medical emergencies - they go for a hangnail - and that's why getting them paid is often a problem for those honest folks who use them for their intended purpose.) and you had no other choice but to see this non-participating doctor, then you have a case for getting it paid, because delaying care could be a detrement to your son.

Insurance companies are generally weasels. They figure if they make you crazy, you'll eventually give up and pay so they don't have to. BUT, if you stand your ground and can document that you did what you had to do, they can't win.

Good luck.

Answer 8

I had been covered by United Health Care until recently. My association with them was excellent as I had (unfortunately) numerous illnesses and hospital stays. The bills I received were well-documented but I found their (United's) customer service folks were always quite helpful should a question arise.

Specifically, I was recently transported to an ER in Northern Virginia, a few miles from the DC line. A MD was assigned from the hospital staff to care for me during my stay (I was admitted and remained in that hospital for quite some time). I, like you, received a billing from United stating that this specific MD was not in United's circle of approved doctors and that, consequently, I was liable for payment for his services. I called United. Customer service stated that I could send a letter of appeal stating the reasons for my appeal. I did so. The other day I received a notification from them that they (United) had agreed with me and that they would be forwarding payment to the doctor in question.

Good luck with them - be honest with them and they will be honest with you.

Answer 9

I take it you're a resident of Virginia...

I don't work with (or for) United Health Care because they don't have good networks available in my area. So, I can't speak specifically to your issue.

However, I do suggest that you contact the Virginia Bureau of Insurance Office of Managed Care Ombudsman. This office exists to assist consumers who are having difficulties with managed care claims. (The link directly to the ombudsman web site is listed below.)

Even if they are unable to assist you resolving your specific issue at this point, they do keep statistics on the issues reported against each insurance company and they watch for trends. Insurance companies do NOT like to hear from them, because they run the risk of not being allowed to sell insurance in the state if they are determined to be turning down too many legitimate claims.

Oh, and be certain that you tell the UHC folks that you've turned them in to the Ombudsman's office. That usually gets them moving. (And yes, I've given my own clients the same advice when the need arose. I may work for the insurance companies, but my clients pay me to watch out for their best interest!)

Answer 10

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