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UNITED HEALTHCARE UNDERPAYMENT

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kita...:
Thing is, their Usual and Customary Rates are below state reg. And I don't know the exact verbiage that I can use to make them reprocess these claims for higher amounts that are necessary for services rendered.

PMRNC:
I know hindsight is 20/20 but whenever you have a high priced procedure to be done and you are NOT contracted, it's always best to request a pre-determination of benefits. This entails the CPT code, the amount to be charged and the diagnosis. Just like verifying benefits you want to determine what (if any) the patient's responsibility is.  The carrier will NEVER give you the U&C charge as that would be a pre-requisite for any provider to commit fraud, so your result from the pre-determination of benefits will be that the carrier will tell you that they will pay $XX for the procedure you will be performing.  When the procedure is done, the operative report/office notes can be used later if there are any particulars that could not be foreseen when the pre-determination of benefits was submitted which you could use in your appeal and/or request for additional payout.

WITH ERISA (non govt/church based group health plan) you must remember that the dept of insurance has NO oversight. It will NOT  be your appeal, it will be the patient's appeal. If the charge was $5000 and U&C from the carrier was $3000 the patient is responsible for costs above the U&C and any coinsurance as well. If you have the RIGHT AOB that includes ERISA verbiage you can appeal on behalf of the patient (standard AOB's are NOT good enough) you can sometimes manage to get MORE for the service by submitting an appeal as the patients representative. If your not willing to go through this process, the patient bares the burden of financial responsibility.

kita...:
Awesome explanation! Thanks!
 But I was under the impression that even without predetermination, payers have to pay according to the Greatest of Three Law for OON emergency services saying that they must pay either
-in network rates
-the usual and customary rate or;
-the Medicare rate
whichever is the highest amount between the three. But many reps for UHC claim that they pay at ENRP Rates. So it's hard to get them to adhere to this Greatest of Three rule

PMRNC:
Again, I'm still not seeing if it is know this is contracted or not, BUT none the less, state dept of insurance or TX state law will NOT help at all IF these claims are indeed ERISA which is federal. If they are ERISA, it is the patient's claim meaning it's up to them to make any appeal for higher benefit OR have them sign an ARF to give you the auth to file an appeal for higher reimbursement, the other option is to just bill the patient.

As for U&C, this is very difficult to explain how a carrier calculates U&C but you will NEVER know IF a charge is within U&C if a pre-determination of benefits is not done. A carrier is NOT allowed to give out the U&C amount, they are only allowed to tell you that YES your fee is within U&C or NO it's not within U&C. U&C calculations go back to the 1950's and it's outdated as heck and there are many ways to successfully appeal for higher benefit and sometimes the whole benefit. IF the fee was indeed cut for U&C, right off the bat the patient is responsible. Again, if it is ERISA you can have the patient either appeal the decision themselves OR sign an ARF and you can do the appeal.

Do you know if this is ERISA?
Do you know for fact the fee was reduced due to U&C?

If you are a PMRNC member we have some ERISA forms in our members only area (under ERISA) that may help.

kita...:
Well I know for sure that these claims aren't ERISA but and I do not know if the fee was reduced because of U&C but they keep telling me that it's paid at ENRP rates? Are you familiar with ENRP?

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