Author Topic: UNITED HEALTHCARE UNDERPAYMENT  (Read 129 times)

kita...

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UNITED HEALTHCARE UNDERPAYMENT
« on: November 29, 2017, 02:10:25 PM »
I work in an appeals department and currently am working on united healthcare. We have billed Emergency Department claims w/ code 99285 and charge ex: $2,000.00. UHC will only pay maybe $500.00. We know that isn't enough but when I call them and tell them that it was underpaid, the response is always they paid according to ENRP rates and they are upholding their decision. I'm starting to believe that that's just their tactic to deny reprocessing; but I need help! I just started at this job and I want to do really good!

Michele

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #1 on: November 29, 2017, 02:54:03 PM »
Is the provider in or out of network?  If they are in network then they agreed to accept the fees.  If they are out of network then they can bill the patient the full balance.  I personally have not heard of getting an insurance carrier to pay more than their set fees.
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kita...

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #2 on: November 29, 2017, 03:14:23 PM »
These are pretty tricky. Because many don't have contracts so there's no way to see exactly what was "agreed upon." They would process and pay at in network rates but I was told there was another way to get them to pay more. I'm just trying to figure out a way to actually go about doing that .

kita...

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #3 on: November 29, 2017, 03:42:36 PM »
Also we base charges off of Fair Health and Texas Department of Ins.

PMRNC

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #4 on: November 29, 2017, 04:21:16 PM »
Well if any of these claims are ERISA, then state dept of insurance has no jurisdiction.

Next, if there is NO provider contract than carrier is applying U&C, not fee schedule as contracted.

If plan is ERISA it trumps provider contracts. Might want to try ERISA appeals on those. I would also say that you MUST know if services are contracted or not.
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kita...

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #5 on: December 05, 2017, 02:31:05 PM »
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

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #6 on: December 05, 2017, 06:00:30 PM »
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.

Linda Walker
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kita...

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #7 on: December 08, 2017, 09:51:19 AM »
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

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #8 on: December 08, 2017, 10:20:18 AM »
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.
Linda Walker
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kita...

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #9 on: December 08, 2017, 10:43:40 AM »
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?

PMRNC

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #10 on: December 08, 2017, 11:21:36 AM »
Extended Non-Network Reimbursement Program -https://broker.uhc.com/articleView-16399   

Looks like it's most likely patient responsibility. There is a link however for "MEMBERS" if they want to arbitrate or dispute balance due bills.

In doing a bit more research it looks like UHC launched this a few years ago in FL, AZ, TX and Missouri.. it also looks like it's based on higher reimbursement than U&C BUT lower than if providers were participating. This means your claims were processed as OUT of network. Means you have every right to bill patient for any balance due.
Linda Walker
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kita...

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Re: UNITED HEALTHCARE UNDERPAYMENT
« Reply #11 on: Today at 03:13:02 PM »
Do payers not have to adhere to the Greatest of Three rule? Even if it is out of network, it can still be paid at an in network rate, or whichever is higher.