I had a procedure done out of network on August 25. The surgeon is well-known so he has a reputation to protect and uphold. He has a dedicated staff member to help patients with insurance reimbursement. My claim was submitted to UHC on September 8 electronically. I phoned UHC to inquire about the status of my claim on September 18. They said they had no claim for me. I quickly called my surgeon/provider's office and the woman in charge, who had already submitted the claim once, got on a call with them and re-sent the claim via fax. UHC suggested it would expedite matters rather than sending it via snail mail. I called again, they had difficulty finding the fax but finally did. They said it would take 30 days or less to process the claim… A $12,795 which I paid out of pocket.
I called again on October 1. They told me they'd just sent a letter to my provider on September 27th requesting additional information about medication that had been administered – they don't reimburse for medication, firstly. I had a spirited conversation with them asking why they waited more than a month after the surgery to request additional information. They had no excuse. They said it would be another 30 days from then. I phoned again at the beginning of the second week of October. I was transferred to a "patient advocate" who asked me to repeat the story for now the 9th time. I did. She said there was something "fraudulent" about the claim that was being investigated. She said the claim was for $39,000! I argued with her because I had a copy of what had been submitted to UHC right in front of me, which was for $12,795.
As my ire increased she made an effort and noticed that, hmmm, some of the claims seemed like duplicates. Long story short, some moron at UHC had opened a SECOND claim – yes, because they had requested it a second time from my surgeon's office. I spoke to the plan sponsor whose contact details I have because I sat with the group when UHC pitched to be our insurance provider. I was very opposed because of previous experiences with this disreputable company who said they would intervene.
It was finally determined that in fact UHC had made an enormous blunder – surprise, surprise. And then they said the claim was going immediately to the "pricing" department. This is a very simple task – they look at each item on the claim, check it against a code, and then determine how much (supposedly 70%) of that amount they will reimburse.in my case there was the surgical suite, the anesthesiologist's fees and the doctor's fees to be "priced" – three items. It is now November 9 and I have yet to see a penny from these thieves. But I continue to pursue the matter and assume I will ultimately be reimbursed. They have submitted a proposal to my company for a renewal contract, to which I have stamped a huge NO and will do everything in my power to boot them. The entire company is made up of illiterate buffoons.