Author Topic: uhc underpaying out of network claim  (Read 1375 times)

zakassam

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uhc underpaying out of network claim
« on: March 03, 2013, 03:00:11 AM »
Im having an issue with united healthcare, we are not contracted with them and we sent in a claim for 2 MRI's billed at 3000 each, and they gave us an adjusted rate of 260 dollars per procedure? how do i correct this? normally the adjusted rate is 2700, not sue what to do, ps i am extremely new to billing. thanks for the help

PMRNC

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Re: uhc underpaying out of network claim
« Reply #1 on: March 03, 2013, 09:30:26 AM »
If you are NOT contracted with the carrier their allowable is based on U&C which means that the patient is responsible for the out of pocket UP to the billed charge. You would not have a contracted rate with them if you are not contracted with them. Look at your EOB, does the amount not paid have an explanation next to it that says it was cut for reasonable and customary or usual and customary? As long as you are NOT contracted you can bill the patient for the full balance up to the billed charges.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
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zakassam

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Re: uhc underpaying out of network claim
« Reply #2 on: March 03, 2013, 10:29:11 AM »
Yeah i understand that part, but my question is how do they justify paying that little for an MRI when the allowable rate they gave me on an ultrasound is 2000? and the costs on MRI's are extremely higher. Im looking for a way for them to readjust the rate.

thanks

PMRNC

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Re: uhc underpaying out of network claim
« Reply #3 on: March 03, 2013, 01:31:13 PM »
Again, it depends. Look on the EOB. Is there anything about U&C or R&C?  If so that means it's based on the standard calculation (HIAA 90th%)  You can appeal, yes, SOMETIMES they will release more.. nearly never will they release all. In cases with R&C/U&C appeal the insured stands a better chance at appeal, ultimately the responsibility is theirs because again, it's Out of Network.   When dealing with R&C/U&C there really isn't an "allowable" like with participating.

Just a side note, but this is EXACTLY why physicians should NOT bill "allowable" fees per network. The rates carriers use is based on a standard calculation BY geographical location, this is a problem when physicians try to cut back on their adjustments (which makes no sense to me) by billing the allowable per plan, that means the charge being captured is going to be LOWER.  So not only does it mess up reporting features when you want to capture data based on adjustments but your also giving the insurance carriers lower fees which will result in lower reimbursements. 
« Last Edit: March 03, 2013, 01:39:22 PM by PMRNC »
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

LASHUNDA

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Re: uhc underpaying out of network claim
« Reply #4 on: April 11, 2013, 08:34:32 AM »
You can appeal Usual and Customary rates.  U&C rates are based off of national rates.  Unites accumulates data from across the country when claims are filed to their carrier.  Ingenix is the company (now called Optum) that does this.  If you can prove that doctors that do the same types of test in your local area are paid more than $270 for the tests and support it with data United will pay more.  You can also write a letter of appeal and in the letter state that you do not accept U&C rates and that you expect to be paid at a percentage of the medicare rate or at least what Medicare pays.

Sometimes it works and sometimes it doesn't but it doesn't hurt to try.  I've been able to turnover some U&C rates paid to my physicians claims.