Author Topic: United Health Care / Optumhealth  (Read 1366 times)

2012billingrep

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United Health Care / Optumhealth
« on: May 31, 2014, 08:31:45 PM »
Does everyone billing for UHC have a capped payable amount of $45/day? This has been the case for us which we understood to be the doctor's contract but now we are seeing that some claims break the visit into separate sections and they pay separately for each section.

ie if we had a new patient and billed out
99203-25
72040
72100
98941
98943
G0283
97010

When we received the EOB, they separated it into several sections and this is how they paid:

99203-25
98943
G0283
97010
Allowed Amount $45

72040
98941
Allowed Amount $45

72100
Allowed Amount $45

We have called UHC multiple times about this and they keep saying it is processed correctly. We were also told that the doctor's daily capped rate is different and separate to what is allowed and therefore paid or owing by the patient. In the case above, the patient still has a deductible so we would be charging them $135. Is this right? I'm not understanding how a capped $45/day rate can be $135. The odd thing is this happens for some of the claims over different patients. For most of them, the $45/day allowed amount applies.

Does anyone know about this that can help advise??

PMRNC

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Re: United Health Care / Optumhealth
« Reply #1 on: June 01, 2014, 12:09:49 PM »
Yes, capitated plans can be done based on cap rate, but we really can't answer that without knowing how the contract reads. I suggest having someone well versed in full credentialing take look at the contract.

The deductible is based on each Patient's plan, not the UHC contract.

You also want to be careful about "fee sharing" .. though you didn't mention any particular physician just so you know to be careful if you speak to others and not mention particulars of a contractual relationship.
Linda Walker
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