Friday, November 7, 2008

Tips on dealing with United HealthCare (UHC)

If you need a new hobby, please consider the joy of insurance claim phone calls! I have two obviously fraudulent claims with UHC. One: I want them to pay me back for my eye exam, which is covered at 100%. Two: I want them to help pay for Nea’s speech therapy. I know, I know. Crazy talk.

After, lo, these many painful hours of dealing with UHC, I’m ready to share my knowledge.

When calling, after you enter your subscriber number and date of birth, say “representative” if you want to talk to a person. When you are on hold, if you say "shut up" the recording will stop telling you about their worthless web site. You may need to say it a few times. Forcefully.

If the person on the phone can’t help you, ask for a “rapid resolution specialist.” They can fix things the Tier One people can’t. And they won’t tell you the magic phrase (“rapid resolution specialist”) until you’ve wasted hours of your life. If they don't want to pass you on, just keep using the magic phrase: "I'd like to speak with a rapid resolution specialist.”

If you have an ongoing complicated case, ask to be assigned a “care coordination case number.” It probably won’t help, but it’s worth a shot.

If you want them to cover an out-of-network provider at the in-network level, you need a "gap exception" -- another magic phrase they won't tell you about. If you are lucky enough to get a gap exception, make sure you take the reference number to your provider! UHC won't do that for you, so you'll continue to be billed at the out-of-network rate.

When faxing, don’t bother. You can fax and fax and fax, even “to the attention of” someone’s name, and they will claim it didn’t arrive or is illegible.

Just now I found the Patient Advocate Foundation.
They list all the State Insurance Commissioners Offices contact info, which probably would be worth a try if you have been trying to get UHC to cough up for a few months without any resolution in sight.

And my number one tip? Switch to another insurance company as soon as your company lets you. Thank god my long nightmare is nearly over.

If you have any tips, please post a comment! If any of these tips help you, please shop Amazon through my link. All proceeds go to charity.

11 comments:

Steve said...

Painful. With the wife recently leaving the freelance world, we are no longer sending BC/BS $400-something a month for coverage on the two of us that still somehow left us paying 95 percent of the cost of her asthma meds and baby-prevention medicine.

Guess who our new insured be!?!?!?

Anonymous said...

Thanks for your helpful hints. I'll try them. I'm trying to get a gap exception for a major test that My IN-NETWORK doctor order. I need a gap exception because the local hospital doesn't take UHC and the closest hospital with a similar machine is 125 miles away. The cost of the test will be paid by me because it is cheaper than my high deductible, but I need the deductible to be applied as in-network not as out of network. They say they'll give gap exceptions if there is no in-network facility for 30 miles, but when you ask for one, they claim whatever you're asking for is not included under the gap exception rule. It's a way of getting out of paying just like the scheme they had going in New York,etc. as a way of having the client paying a larger share of costs than they should. It's a scam.

Anonymous said...

Gap Exception is a clause that an employer can choose to offer as a benefit to it's employees. Not all UHC members are eligible for this, plain and simple. In order to be eligible, there are certain parameters: the Gap has to be in the benefit plan(this is decided by the employer), and there has to be no contracted provider within a 30 mile radius of the home address of the member. If BOTH of these criteria are not met, you WILL struggle to get coverage for the service. The employer is who chooses what is and is not covered, NOT the insurance company. All they do is administer the plan. The insurance company doesn't make money by denying claims. They keep the contracts with employers by correctly processing claims and a few other factors. I promise you, if something isn't covered, it is not the insurance company's fault...look to the benefits administrator at the company you work for...they are the ones who "shop" insurance companies for plans, then offer them to employees.

Anonymous said...

I'll be honest...it's not a "scam". The industry is regulated by state law and the NAIC/CMS. There are a LOT of factors that go into each and every rule regarding coverage. We may not always like them, but they are there all the same. The people that answer our calls are people too, and they get screamed at all day long, even though none of them have a personal hand in those rules. I respect those people, and their tolerance to withstand the abuse they get. The industry needs revision, but here's a thought...banks have been around for over a hundred years, and they have issues...the insurance industry, which started with simple HMOs, has only been around since the 1960's...we can't expect it to be perfect. To those who don't like it, cancel your insurance, and see how that works out for you.

Anonymous said...

Anonymous said "To those who don't like it, cancel your insurance, and see how that works out for you."
When I pay my premium for services outlined within the unilatteral conract written by the insurance companies and they take my premiums every month, I expect them to uphold their part of the contract when I have a claim. I expect that they do so in an efficicent manner. Over 30% of UHC claims are denied every year. Most of those claims are legitimate and should have been paid. This is not ethical or even legal, but they know that most people do not have the time nor expertise to go through their layers of administrative "rules", give up and pay for the service out of pocket.
Your option of if you don't like it, self insure is rediculous. There are many more options available to insist that a contract be inforced and if it can be proven that there is willful denial of claims, punitive damages to correct the wrong behavior by a company should be levied against it.

Anonymous said...

If someone gives up and pays for something out of pocket because the claim didn't process correctly, the insurance company doesn't get your money, your doctor does. There is no scam on the part of UHC, nor do they benefit anything. UHC gains profit only by having contracts with the doctor's offices. The premiums you pay for insurance go to your employer. The amount of money you pay for a medical procedure go to your doctor. The insurance company gains nothing if your claim is denied or paid. UHC is a multi-billion dollar company, think they are scheming to deny your $75 flu shot? Insurance, like everything else, is based on a contract, read your contract before you complain.

Anonymous said...

Please don't try to hide the pea under a different shell. Premiums may go to the employer, but only because UHC is paid by the employer to provide coverage. The issue is that insurance companies work on the spread between what they receive in premiums (regardless of who pays them) and what they pay out to claims. They have significant incentive to delay or avoid paying every claim they can. Thousands of individual experiences indicate that part of those "multi-billion dollar"s are, in fact, unpaid claims kept as profit rather than paid and expensed in accordance with the contract.

Anonymous said...

Thanks for the info. Do you have any tricks on how to bypass Claims - it takes an average of 8-10 minutes to finally get transferred to Rapid Resolution?

Anonymous said...

State mandates mean nothing if your employer is self-insured. Basically your employer decides what to cover and the federal government lets them get away with it.

Trying to even figure out how to appeal half of the denials we get is near impossible. You can't keep referring me to a website, United, if your website is useless.

I finally talked to an "advocate" hired by our company to deal with the problem people. She admitted to me that I knew more about the benefits than they did. I wanted to request a copy of that audiorecording.

When I called United last it was to request a fax number so I wouldn't have to mail in my claims. I was on hold 10 minutes to talk to a representative for 18 seconds.

Anonymous said...

Oh - since United Health Care doesn't publish those claim fax numbers anywhere, here they are:

801-567-5499 Salt Lake City
801-567-5497 Told this by a diff rep
801-567-5498 Told this by a 3rd rep

I just fax it to all 3. They make me spend my days dealing with paperwork so I like to repay the favor.

PJS said...

Thank you for your explanation and advise on gap exceptions. As for cancel your insurance if you don't like it anonymous comment. Lets see how fast my insurance would be cancelled if the insurance company did not receive my premiums in a timely manner. However they can hold payment until they see fit to make good on there end. If it is anything but routine visits, the policy holder may have to make several calls before resolution. My time on the phone cost me money, the longer the insurance company holds on to money , makes them more money. If you end up paying for something out of pocket , YES the insurance company wins because they keep the money that they should have paid.... Not a scam , I beg to differ. Yes I feel sorry for the people that are mistreated because of the games they are forced to play in order to keep there jobs. Not all insurance companies operate this way. I have spoke to several caring associates at UHC, But I have also talked to others that made it abundantly clear that they were in the business to make money, and left me with the impression that It wasn't there problem they had no in network providers. I have found that alone I am no match for the insurance company and have contacted the State Department of Insurance.