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I have Medicare as primary and United Healthcare as supplemental.  I first purchased Ampatches and catheters from Austin Medical and was advised that they would bill Medicare, who would process the claim and forward billing to UHC with the balance not reimbursed by them.  Two claims were made in this fashion during 2013 and I received checks from both Medicare and UHC.

 

In 2014, several clams for covered supplies were filed in the same manner.  I did not expect any reimbursement on the first claim from UHC since my annual deductible had not been met. Later in the year, I contacted UHC when reimbursements were not forthcoming and was told that they were refusing secondary coverage on the basis that Austin Medical was not an “in network provider”.  I appealed this action citing their 2013 reimbursements and failure to disclose a change in reimbursement practices for supplemental coverage.  My appeal was rejected and I am contemplating making a request for an independent review and a possible complaint to the Wisconsin Insurance Commissioner.  Has anyone had this experience with United Healthcare and were you able to get a satisfactory resolution?

Bill

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I can't comment on the merits of your appeal specifically but I mentioned elsewhere that insurance companies seem to change rules, deductibles etc. every year and it's hard to keep track of things and most definitely they frequently don't tell you about coverage changes.  I started a thread on how they changed copays on Xifaxin (Anthem).

 

Yesterday I got a notice of class action change in compensation in the class action against Health Net.  I am part of the Health Net Class Action and I got a small piece of compensation and now some adjustment is being made in the settlement.  Did anyone get that letter besides me?

 

Bill good luck with the appeal and who knows maybe UHC will also deal with a Class Action at some point. Health Net was a nightmare and I filed appeals with them similar to what you are doing now on out of network coverage issues and that is how I ended up in the class of litigants against them. Suing and filing insurance complaints with insurance comissioners is the only way to keep them honest.  Good luck.

I'm on Medicare and have UHC secondary insurance. Everything was working fine with them until they decided not to pay their part to the Mayo Clinic.  I was getting bills but figured they were just slow with their payments.  Come to find out, they were not paying anymore.  I now have to call Mayo's and they have to resubmit some how.  The first time this happened it was for around $2000 and that got my attention right away.  I feel for people, like my grandparents, that go ahead and pay the bill not realizing UHC is ignoring them.  

 

Ray, the only complaint I have with Medicare is they use an unrealistic cost of around $11 for catheters that cost $26, thus reimbursing only $9.  With the exception of my 12/2014 claim, Medicare forwarded all billings to UHC, and it is UHC that is at fault in this matter.  Prior to filing my appeal to UHC, I talked with Bernadine (who handles billing) at Austin Medical who was surprised that UHC refused to reimburse what Medicare did not pay. Unfortunately, she said that there was nothing more she could do in dealing with UHC, but she did send me billing copies that she thought might be helpful for use in my appeal.  To add insult to injury, in 2015 UHC increased my annual deductible and maximum out-of-pocket cost by 50% and my cost of an office visit by 300%.  I suspect that the Unaffordable Care Act could have some blame for that.

Bill

Mayo's says it's UHC.  They file with Medicare and Medicare forwards it to UHC after the Medicare approved rate is determined.  Mayo billing has somehow re-submitt to Medicare and then UHC finally pays.  She told me to call them every time I don't see UHC paying after Medicare. Unfortunately Mayo can't take care of it with the first submission to Medicare.  I'm not saying that Medicare is perfect, just what is happening at Mayo wth my account.  UHC has more than one plan too.  I bet Bill's UHC and mine are different.  I'm paying for mine through my husband's retirement health benefit plan. We have to pay the same premium now for secondary as it was when it was my primary and only insurance. When I became eligible for Medicare at 24 months of  being disabled all this happened. This is a federal regulation etc.  It is all too complicated and favors the insurance companies.  IMO the sicker you are the more you pay for insurance and I haven't seen any evidence of change to an easier way since Affordable Health Care was passed.  

To update on my February, 2015 appeal, I finally received a check from UHC for the amount I had originally requested.  Success finally came when I filed a complaint with my state’s insurance commissioner.  It is unfortunate that I had to go through two levels of appeal with the insurance company and a refusal by the independent review agency to hear my case.  All this took time and money by those involved.  For those faced with similar problems (and being able to present a good case), I would suggest pursuing the matter like I did.  Perhaps that will encourage insurance companies to “get it right” the first time.

Following my last post, I deposited United Healthcare’s reimbursement check.  They subsequently stopped payment on it with no prior notice and my bank charged my account with a bad check service charge.  Apparently, UHC decided after issuing the check that they were not going to favorably respond to my appeal.  I complained to UHC about this and they said they would reimburse me for the bank fee, but have not done so.  So much for their statements in their correspondence that they value customer satisfaction. 

Sounds like time to file another complaint with your insurance commissioner, as this sounds illegal to stop payment on a settlement check that they agreed to pay. I'd say file a law suit, but you'd have to be very motivated and P.O.'d enough to get into that can of worms. Insurance companies are very good at dragging things out until you give up. You could do small claims court just to yank their chain, but you have to decide how much your time is worth. 

 

You can imagine there are numerous others being jerked around by the same outfit. Class action suit?

 

(By the way, I don't think that the Affordable Care Act affects Medicare. It is only for those not eligible for Medicare).

 

Jan

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