Three Years Later, United Health Care vs Me

[plainlazy]

To cut a long story short, my wife had a horrendous case of Endometriosis back in 2005, United Health Care (PPO) paid some, but refused to pay a bunch of bills that her doctor felt they should've and still should.

It's over $11k of bills and late fees now. My next move was to write a letter to the National Appeals Service Center, but I'm afraid that might be too little, too late.

Any help would be crucial at this stage as i fear we will be sued pretty soon.

thanks all

[lealea1005]

To cut a long story short, my wife had a horrendous case of Endometriosis back in 2005, United Health Care (PPO) paid some, but refused to pay a bunch of bills that her doctor felt they should've and still should.

It's over $11k of bills and late fees now. My next move was to write a letter to the National Appeals Service Center, but I'm afraid that might be too little, too late.

Any help would be crucial at this stage as i fear we will be sued pretty soon.

thanks all

Is the surgeon contracted with UHC, or out of network? When did you first start contacting UHC about the bill? What reason is given, on your explanation of benefits from UHC, for not covering the service?

[plainlazy]

Out of network, but accepted a discount on the service. They contacted UHC many times for us, but our first contact was march 06 ...the surgery was performed in mid-late 2005.

They did pay a bunch of stuff, but for some reason a denial was made upon CPT code 99213 is not payable due to "procedure or supply is part of the global service".

We claim that their reviewer misunderstood the situation, simply that could not be part of other service, specifically according to code guides that 99213 is not part of 76856 or 58350. We never got resolution from this.

At least that what i've been led to believe, i'm really out of my league here, and am paraphrasing the doctors letters to UHC.

[lealea1005]

Out of network, but accepted a discount on the service. They contacted UHC many times for us, but our first contact was march 06 ...the surgery was performed in mid-late 2005.

They did pay a bunch of stuff, but for some reason a denial was made upon CPT code 99213 is not payable due to "procedure or supply is part of the global service".
We claim that their reviewer misunderstood the situation, simply that could not be part of other service, specifically according to code guides that 99213 is not part of 76856 or 58350. We never got resolution from this.

At least that what i've been led to believe, i'm really out of my league here, and am paraphrasing the doctors letters to UHC.

UHC does refuse payment on a 99213 if it's within the "global service" period (usually 7-14 days of surgery) if the diagnosis code (ICD9) is the same when they submit the claim. Was your wife being seen as follow up from her surgery? What was his charge for 99213 and is he still willing to accept UHC's in network payment for the 99213 as payment in full?

[plainlazy]

Thanks for your help so far, i did some more research, it appears 99213 is only a small part of the problem ....but you are right it was a follow up.

The larger issue at hand costing thousands of dollars was the surgery performed (Laparoscopy & Uterine Suspension). All we were told by UHC was "this is not a separately reimbursable service". Which sounds contrary to the American Medical Association CPT Code, and rules of processing the claim.

thanks again!

[lealea1005]

Thanks for your help so far, i did some more research, it appears 99213 is only a small part of the problem ....but you are right it was a follow up.

The larger issue at hand costing thousands of dollars was the surgery performed (Laparoscopy & Uterine Suspension). All we were told by UHC was "this is not a separately reimbursable service". Which sounds contrary to the American Medical Association CPT Code, and rules of processing the claim.

thanks again!

Yes, this is how ridiculous it has become. To make them reimbursable as separte services, you would have to have the procedures done at different times (exclusive of UHC's "global surgical window"). It costs more all the way around, not to mention the risk to the patient.

You could always ask the surgeon if it was coded with a modifier indicating both procedures were done at the same time. However, experience tells me it would not have made a difference as far as UHC was concerned.