United Health Care, not content with merely denying life saving cancer procedures or refusing to pay for basic (covered!) checkups, took things to a new level by retroactively un-approving procedures they paid for in 2005. They sent reader Suzanne a letter and a bill for $7700, claiming the pay-out was an “administrative error”, and she needed to pay up. Check out the details, inside.
Hi there – I’m really hoping you and your readers can help me with my problem. I had two procedures done in December 2005 (laprascopy and a hysteroscopy). Prior to the procedure I called United Healthcare (my provider) and asked them if the amount the doctor was charging was considered reasonable. I didn’t want to have these procedures done by this particular doctor if insurance would not cover the cost (I had another ready to perform the procedure who was in-network). After being reassured by United Healthcare that the cost would be covered I decided to go with the out of network provider. A few weeks later I received almost the full amount for the procedure – they covered about 90%.
This week I received a letter from United Healthcare telling me that they made an administrative error and that they wanted me to send them a check or money order for 7700 dollars! This is almost three years later!!
I’m shocked and plan to appeal. Can they do this? I mean, it is almost three years later!?!?
I know UnitedHealthcare is really horrible when it comes to claims/billing but this is insane.
Thanks for any help you can provide.
Suzanne
Yeah, of course United Healthcare sees paying for your procedure as an “error”. We sent Suzanne to our list o’executve email addresses for United Healthcare, and hopefully she’ll be able to convince United Healthcare that this is just ridiculous. They approved her claim years ago, and they’re just going to have to deal with it. Unless, of course, Suzanne forgot to call “no takebacks”.
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@Jmatthew: Oh, I see you don’t understand what pre-tax medical savings accounts are. You reserve money pretax that you must use by the end of the year, administrated by your insurance company. They give you a debit card for the amount you reserve that you use on medical expenses and verify that the purchases are valid.
That’s how they get involved in this. The insurance companies like these programs since they make money off of the float for little effort. And, as it turns out, even less competence.
Better go read the policy.
Over payments (for whatever reason) are refundable to the insurance company. BUT (big huge BUT) there is a specific statute of limitations. Per the terms of my policy it is 180 days.
@Pithlit: Ya, it may be old. But Fact is Fact. An Old fact is still a fact.
But hey, lets do it. We can all agree that taxes are not high enough right? We all agree that the Fed is very efficient, and would not possibly mess it up…..
If you go to court, rely on this:
[en.wikipedia.org]
There are a few things I would want to know to help out on this.
1) What state is this in?
2) Are claims paid with United’s money or with your employer’s money? (That makes a difference as state mandates would not apply to plans paid with your employer’s money.)
3) What type of plan did you have, HMO, PPO, etc? There different requirements, both state and federal, for the different types.
Without knowing these answers, I have 2 suggestions for you.
First, go to your HR team. If you voice your concerns with your HR team, then the people picking the plan administrator should at least hear about the issue for future decisions. However, they might be able to reach out to a contact at United that can look into it.
Second, go to your state Department of Insurance. If you file a complaint with the DOI in your state, that gets the attention of the insurance company. Most DOI’s require the insurance to respond within a very limited amount of time as well.
@Jinx: The hell with a lawyer…tell them that claims must be submitted with 6 months and she’s denying their claim. Then offer to let them appeal.
Take your own medicine United (hopefully it’s covered and you won’t have to pay more than the co-pay)
My young son is battling cancer. We know other parents via our online support group in other countries who are desperately wanting access to some of the treatment methods, super-speciailized high-end equipment, and drugs we have available here in the USA. But the availability is very low or nonexistent.
And there are certainly problems here in the USA as well. We see battles with insurance companies over covering treatments and drugs because many early-adopter procedures aren’t in their book of standard treatments.
But based on our particular experience with rare and complex health problems, the USA has some of the best hospitals, scientists and available treatments in the world.
All systems have their problems, and those believing a magical system awaits the US to solve all our problems are almost certainly mistaken. IMHO, this is a great CONSUMER story about a company doing something idiotic and needing pressure to get them to act sensibly.
@coffee177: Have you ever lived in a country with universal health care? I live in England now, and I need to see a dermatologist frequently because I have severe psoriasis. In America, I had to pay between $20 and $40 (depending on the which insurance company I was with) to see a doctor who would keep me waiting for 45 minutes, talk to me for about two minutes, and then send me out with a prescription for another expensive medicine that would cause bone marrow and liver damage. Here in the UK, I’ve never spent less than ten minutes with my dermatologist, who has discussed with me the best options for my skin given my extensive history and worked to find the medication with the fewest side effects. And prescriptions never cost more than seven pounds. The NHS may not be perfect, but having experienced both systems, I’m happy to be living in the UK.
@alice_bunnie: Ah yes, the old canard.
Despite all the waiting, somehow, people in countries with OMG SOCIALIZED MEDICINE live longer and are less likely to die from an amenable cause, while paying less per person and as a percentage of the GDP.
Based on your argument, it makes waiting makes you healthier and saves you money. Put me on the waiting list, doc!
@SonicMan: Except it’s not a fact. It’s just a bunch of cherrypicked anecdotes.
Ok, I’m going through a similar thing with Delta Dental. My son needed crowns on his 2 front teeth after an accident. A “pre-determination” was put through by the dentist (or so I thought, now I’m not so sure) for the procedure. The would cover $1,000 of it. We had it done. Now they are saying they will cover $0.00. WTF????? Can they do this after a pre-determination????? Help!!!!
A few weeks ago, I was at an outpatient facility,waiting to go into the operating suite for cataract surgery. CIGNA had approved the in-network procedure, they’d pay $2000 and I was responsible for the other $2200. There goes my tax refunds. Anyway, the front desk person said that they’d just opened the claim with CIGNA and it was immediately denied, with the code for pre-existing condition. I had to cancel the surgery and I’m still dealing with CIGNA to determine what’s covered and what isn’t.
We may have the best hospitals, best trained doctors and nurses, and fantastic equipment, but if you can’t afford it, it is worthless. Why is my employer paying $450 a month with me kicking in another $200? Why is my deductible $4000? Why are “maintenance” prescriptions (anything prescribed for more than three months) not covered? Oh yeah–choice and the free goddam market.
Cue the posters blaming me for being an unhealthy whiner.
@Papa Midnight: Ha!
@coffee177: Let me be fully against that. I’m from Spain, Thus a UHC country and my high school friend that went into med school is now making more that any body in our generation.
We go a long way especially since both of us went into the army, and even then he was making more than most of us that had the same rank, and when I say more than us do consider that we earned quite a living wage.
So there. Of course I cant say much for the US health care, never been in a US facility, all my visits are business and never near a Hospital.
@coffee177: Doctors moving out of country… that’s a huge stretch and a flat out fictional lie. I know quite a few doctors, and they are not going anywhere no matter what the system is. They will continue to be high dollar earners.
Your imagination (or someone else’s imagination) has gotten the better of you.
Our previous health insurance tried this nonsense about 9 months after the fact. They suddenly decided that they didn’t owe the money first they said it was preexisting, then they said it was an accident so they were not the primary responsibility. All were neither.
I spent way too much time over three months arguing and tackling what they threw my way. They purposely flood you with paper. The trick seems to be to dump things that require you to do or prove something with a short time limit in the hopes that you don’t do it.
@Ex_EA_Slave: You don’t know that. In fact, NONE of us KNOWS exactly what the circumstances are, so you can really draw NO conclusions.
@BruinEric: I wish the best for your son. My brother got cancer at at 3, was told he wouldn’t make it to 6, and is going to graduate high school next month. So, there is always hope.
I’m sure she didn’t submit the claim. The doctors office submitted it and the insurance company paid the doctor. I think Sue and the doctor performed their duties in accordance with accepted procedures. Sue needs to get the doctors insurers (malpractice and business) involved which would probably stop this in it’s tracks.
@coffee177: Of course, You can still gamble on Universal health. Leaving the sponge in, Mixing up your charts, discharging you too early
Funny you should mention discharging too early, because that’s precisely what insurance companies are pushing these days. Case in point, when our daughter was born, we were discharged 36 hours after the delivery and the hospital failed to detect jaundice, so we had to be readmitted for two extra days under the bilirubin lights.
Essentially, they tried to cut costs by discharging early, a policy meant to cut costs, a shorter turnaround, ended up costing them more, not just for the treatment but for the extra paperwork for readmittance, which they could’ve avoided by having a more reasonable timetable for recuperation, not to mention they missed a serious (albeit easily detectable and treated) condition.
@Sir Winston Thriller: This actually is a very different situation than the original article, other than involving insurance, but this info may actually help you out.
Due to HIPAA legislation in the US, if you have prior group health insurance, without too long of a break, you can get credit towards the 365 days that the pre-existing condition limits could impact your coverage. If this is the case, your prior carrier can supply a letter of credible coverage. Submitting this to your new coverage can meet some or all of the period you would have to wait for the limit to pass. Also, if your new employer has a waiting period before your coverage can begin, the gap in coverage goes from the end of the prior coverage to the beginning of the waiting period, but the waiting period doesn’t contribute towards the number of days met on the pre-existing limit.
If you did not have a prior medical coverage or the gap between the 2 was too long, then it may depend on whether you had received treatment or diagnosis of your condition prior to your effective date. Your physicians can help out with that by providing the information to your insurance company.
I hope that helps you out.
@failurate
And how would the remain high income earners when the government decides that they’re making too much money and need to make budget cuts?
Would you as a doctor, like to make as much as a teacher?
Wow. There’s a lot of bad information being thrown around here.
Too many details are missing from all of the insurance stories to give accurate answers.
To all of you, I suggest looking up a “Medical Claims Advocate” in your area. These are people who are skilled in dealing with sorting out billing and claims errors. Most will give free consultations over the phone.
Here is the website for the Alliance of Claims Assistance Professionals. You can find someone near you on this site:
[www.claims.org]
@coffee177: “Of course, You can still gamble on Universal health. Leaving the sponge in, Mixing up your charts, discharging you too early, Oh and the fun one. Waiting forever to get in and then seeing that since you waited soooo long that now its cancer!”
Thank god this never happens in the current US healthcare system.
Is it arrogance or brainwashing that prevents people from admitting that, gosh, our system sucks, and, gee, there could possibly be a better way, and — oh my god — some other countries are already doing it!?? No, couldn’t be, this is the USA and we’re the best of the best.
It’s like someone handed you a turd to hold on to, yet told you it’s the best thing in the world. Nevermind that it smells like a turd or it’s brown or is all squishy and it *was* warm when you first had it, and that people from other countries are saying, eh, why are you standing there holding a turd?
@Msclear and etc: You’d have some really good points if you were really arguing against a free-trade health care system.
But what we have is a corporate based health care system right now. If anything, it’s closer to being like a universal one than like a free trade one, in that someone other than the consumer is paying and someone other than the medical profession is deciding the costs.
This is like saying we should give everyone free cars because the car insurance industry is out of control.
I think it’s useless trying to convince the free marketeers that there is indeed a better way. Yeah we have choice in the marketplace, but it’s between constipation and diarrhea. The only “choice” we have these days is between varying degrees of shit plain and simple. Unfortunately too many people are blinded by assholes like Rush Limbaugh and Michael Savage to think for themselves.
Y’know, there are folks in this country with some conditions that can’t get insurance at any price? Folks with Diabetes for example, most insurance companies won’t carry them and blame any health problem on their pre-existing diabetic condition.
Hell, I can’t get insurance at any price either, at least not to cover any Mental health treatments, insurance company will just say “pre existing” as the magic words and deny any claim. Heck, United Healthcare denied me a mental health claim despite having NEVER Been diagnosed or treated for mental illness before. I told the hospital that’s STILL trying to collect from me to get bent and take it up with UHC.
We definitely need the Single payor system BADLY. All the free market has done is given carte blanche for the insurance companies to fuck every American in the ass. I won’t bother to pay for insurance anymore because it’s a crap shoot weather or not the motherfuckers will pay.
It is estimated that 27K Americans die every year due to not having health insurance.
UHC sucks. They are the worse insurance that I have ever had or heard of. They just announced a bad quarter and they keep loosing customers. What a surprise. Empire BC is like heaven compared to them and in the end, much cheaper. If UHC was removed from this earth, then life would be better for us.
TechnoDestructo.
UK and Canada being the only contries with it. Dang, I must have missed something during those 22 years living in Norway and the 5 years in Sweden, Because I was pretty sure we had it. After all every medical bill and drug was covered by the state. Except a small personal fee of around 20 USD pr visit, or 16 USD pr day in hospital.
Waiting times being longer.. yeah it happens in Norway, it happens in the US. I take my chances on them in Norway, instead of taking my chances on a possible insurance coverage.
UHC is the crappiest, most useless insurance company I’ve ever had the displeasure of having to deal with. I was very happy when my company “fired” them & went with another provider.
@Craysh:
Yeah, doesn’t work that way *at all* in Germany. Please actually do a little research into countries other than Canada before you start spouting bullshit. Thanks.
@Black Bellamy:
Are you an attorney? Can I get you on retainer?
@coffee177:
“Not a problem. Let me summerize it for you so you can understand:”
Given that you’ve substantiated none of your ‘reasons,’ you’ve only presented opinion, not fact. That’s all well and good, since you’re certainly entitled to your opinion, but taking a condescending attitude simply because you don’t agree with someone else’s opinion is quite rude.
IOW, I disagree with your opinion, but I’m not being a d*ck about it. Maybe you could try that yourself.
The state where I live has laws about this very practice of insurance companies trying to recover money paid for claims, and I would suggest that this woman contact the insurance commissioner in her state to find out if her state has similar statutes. This is so, so wrong.
There are companies that specialize in this type of benefits recovery — they hire themselves out to insurance companies with the promise of recovering x times the amount it costs to hire them. I have had physician clients get these letters asking for repayment YEARS after the services were paid for. This is how I became aware that my state has regulations against this practice.
@smirky: Good point. In my last temp job, I had to send letters to people demanding money for waaayyyyy overdue bills. (Christ, how I hated that job…) If they paid, good for the company. If they didn’t pay, there really wasn’t anything the company could do because the bill was so old and the legal fees would outweigh the money collected if they actually won (and then they probably wouldn’t be able to collect anyway). But since this is such a large bill, definately check the statute of limitations on this. But I doubt they’re going to try to collect on this. Even if they win a court case, they know a bill this large along with legal fees would likely send someone into bankruptcy, and then of course they’ll still never collect.
Oh wait…$7700…I guess that wouldn’t really mean bankruptcy. I guess I was being overly pessimistic about the economy there for a second
I was the guy who wrote the Consumerist post about CIGNA retroactively unapproving a surgery they had preapproved and demanding $9000 from me.
They admitted they had approved the surgery, the hospital, the doctor, and the fee. The hospital verified all of that in advance. So did the doctor. Then I got the surgery and they unapproved it 4 months later.
Here’s what you do – fight, fight, fight. There’s a company in New Jersey that specializes in reversing denials-of-claims. Hire them. Have them file an appeal for you. Then, file an appeal of your own. If they’re denied, keep re-appealing. Over and over. Never give up.
Also, call your state insurance commission to see if your state permits robbery of this kind. I live in Ohio, and I was told it was perfectly legal. Their precise comment was, “Mistakes happen, sir.” Ohio’s insurance commission is nothing more than the collections arm of the band of thieves known as the healthcare insurance industry.
Then, vote for politicians who promise to nationalize companies like CIGNA and AETNA and throw their executives into prison for life.
How do insurance company employees sleep at night? Seriously!
I’m in the insurance business. What most people know about the Universal systems in other countries is straight from the mouths of talk radio personalities and bears little in common with the truth. I have friends overseas who love their system and can’t imagine ours. Like it or not, on this topic, Sicko was very accurate.
@Black Bellamy: You win the thread.
[www.npr.org]
I found this article very interesting read. How ironic that in Japan that hospitals are closing down because health care is TOO CHEAP!
Though to be ‘equal’ my brother lives in Japan and hates how the doctor-patient relationship works. It’s very ‘I am the doctor and I am god’ kind of thing. They don’t really share information with you, and if you try to ask or even question them, they become defensive and even hostile. He’s not a big fan of them
I wanted to add something to my post above at 11:10. After the executives at CIGNA and AETNA have their companies nationalized and then go to prison, I want to wait until they die of old age or disease or a prison riot, and then dance on their graves. Then I will find their children and tell them that their parents were bad people and deserved to die, and are now in hell. And when their children cry, I will lick up their tears and savor them.
The last 100 drugs that the FDA approved only 43 were approved in Canada, because some faceless braucraut said that the other drugs were too expensive for canadian citizens. And you guys want that!!
@Ex_EA_Slave: Are you kidding me? Do you even have health insurance? Most company’s will cover out out network but only a certain percentage, for example: My insurance is 100% in and 70% out. This woman did everything right and checked before her surgery. Leave it to you to be the blame the victim commenter in this thread.
To everyone bucking universal healthcare – have any of you ever actually lived in a country with it or do you just get yourinformation from websites like Consumerist? I’ve got friends in various countries around the world who don’t have any of the problems listed nor do they have to wait for surgery for a year.
@Coder4Life:
Wasn’t there a story about that recently….
I work for an insurance company and what I suggest you do is appeal it through customer service. Call every day and then let them know that you are going to file a complaint with the Dept of Insurance. I know personally, that once we have someone that takes a claim to the dept of insurance, those cases are handled as a priority.
When anyone calls in to our customer service department, there is a log of that conversation on our computer system. When you call into customer service to ask/file an appeal, ask them to find the record of your call where United said that they would process this claim at XX% of benefits. When you called United, they gave you a mis-quote of benefits. The company I work for, we have to honor that mis-quote. So that would be my first step.
As for the Dr’s office, they knew they were out of network for this woman and they should have been the ones calling for an auth.
So, Call United and get them to admit to a mis-quote and start the appeal process. Second, contact your states Department of Insurance and file a claim and then notify United that you have filed a claim. Also, call every day to find out if anything new has happened. Being a pain really does work, at least for my company. The more someone calls, the more they complain, the more likely people will be to do something so that you stop calling.
I really hope everything works out for you.
Suzanne: If your appeal does not go through and they continue to insist on payment, simply refuse. No, I am not kidding. Tell them to go jump in a creek. DO NOT PAY THEM ANYTHING. Not a single penny. Do be prepared to switch insurance companies, but you should do that after this fiasco, anyway.
They can not “take” the money from you. They can not FORCE you to pay them. Can they sue you? Well, technically, yes, but I’d be really surprised if they win and you should NOT have to hire an attorney.
So, step 1: Try to work it out with them, but do NOT agree to pay ANYTHING. Don’t even let them talk you into paying half, etc. Don’t give them a penny.
Step 2: If they insist, simply refuse. Shred their letters. Don’t answer their calls. Tell them to jump in a creek, you’re not paying.
Step 3: If they send you to collections (they will), inform the collections agency this is an invalid debt that you DO NOT OWE. There are easy to follow procedures for dealing with debt collectors who are harassing you. Follow them.
Step 4: If they do eventually sue you – highly unlikely – don’t freak out and waste money on a lawyer. Show up to court dressed nicely and remain calm. When it’s your turn, explain the situation to the judge: You had a procedure done, they paid for it, two years later they changed their minds. Explain that you never signed anything agreeing to be responsible for this debt and that you are not responsible for their error. Worse case the judge will make you pay it. But I highly doubt they will take it this far.
As for “Can they do this?” Sure, anyone can “demand” money from you. I can send you a letter demanding money from you, too. Just because someone demands you pay them doesn’t mean you have to. I regularly tell people to go jump off a fucking cliff with their silly bills or bullshit charges. In short, I refuse to pay when I don’t legitimately owe the money and you should, too.
When they scream and threaten you, ignore them. When they say, “I’m going to sue you!” Tell them to go ahead. They like to make threats. They rarely follow through.
Hmmm….the next step in what Republicans want – no health insurance for anyone ever no matter what, because unless they are rich people deserve to die in the gutter.
Isn’t it amazing how disposable everyone is to Republicans and health insurance companies?
Needless to say, their approval and payout of the charges is a contract and they can’t go back on it. Duh.