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  1. #1
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    Nov 2010
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    Default Preapproved, Paid, Now Insurance Wants Money Back

    My question involves insurance law for the state of: Texas
    I am a health care provider in-network with UHC. I preapprove all my visits b/c otherwise they will not pay. In March 2010, I received a notice from a company called J&P, contracted by a company called OptumHealth, contracted by UHC to get a refund for 22 patient visits that had been pre-approved and paid. I sent my notes and appealed and they say the treatment is not 'medically necessary' but they refuse to explain what it is my noted are missing that renders the treatment unnecessary.

    I keep notes according to what I was taught and what I learn in my yearly continuing education classes. I take my job very seriously. I don't appreciate being treated as a shyster by someone subcontracted by a subcontractor solely to bilk money out of me. Every time I contact J&P, UHC or OptumHealth about this, I get a different answer and the amount they want keeps going up!

    I do not want to have to call patients and say they owe hundreds of dollars for visits paid for over a year ago. I seriously doubt they would pay anyway. I have filed three complaints with Texas Dept of Insurance, but they refuse to comment on cases of 'medical necessity' nor will they address the way this whole thing is being handled. Is there anything I can do or is this just another way they slowly kill my soul and drain my bank account?

  2. #2
    Join Date
    Apr 2007
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    Il.(near StL,Mo.)
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    The only thing I know is to bill the patients. They are ultimately responsible for
    anything that ins. doesn't pay.

  3. #3
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    UHC must have conducted an internal audit and changed their decision (I believe they have up to 2 years to do so). The patients will receive updated EOBs from UHC indicating the change, and their responsibily for payment. Unless there is some contractural reason you cannot collect, you should bill the patients. You rendered services and deserve to be paid for your time.

    I assume you have patients fill out a registration form and sign something stating they are ultimately responsible for payment if their insurance company denies or does not cover the service.

  4. #4
    Join Date
    Mar 2008
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    Quote Quoting khchiro
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    My question involves insurance law for the state of: Texas
    I am a health care provider in-network with UHC. I preapprove all my visits b/c otherwise they will not pay. In March 2010, I received a notice from a company called J&P, contracted by a company called OptumHealth, contracted by UHC to get a refund for 22 patient visits that had been pre-approved and paid. I sent my notes and appealed and they say the treatment is not 'medically necessary' but they refuse to explain what it is my noted are missing that renders the treatment unnecessary.

    I keep notes according to what I was taught and what I learn in my yearly continuing education classes. I take my job very seriously. I don't appreciate being treated as a shyster by someone subcontracted by a subcontractor solely to bilk money out of me. Every time I contact J&P, UHC or OptumHealth about this, I get a different answer and the amount they want keeps going up!

    I do not want to have to call patients and say they owe hundreds of dollars for visits paid for over a year ago. I seriously doubt they would pay anyway. I have filed three complaints with Texas Dept of Insurance, but they refuse to comment on cases of 'medical necessity' nor will they address the way this whole thing is being handled. Is there anything I can do or is this just another way they slowly kill my soul and drain my bank account?
    I understand your dilemmea as I had a long talk with my chiropractor on this very issue. I had back pains for many years, and a recent MRI reveals the cause to be a partially herniated disk.

    He started treating me early this year, had a usual set of questions and form which he fills out at the start of each session. I asked him what the purpose of it was, and he tells me that it's part of a treatment plan he has outlined for me and filed with my insurer, i.e the preapproval, and since my health insurer pays for all but the $10.00 co-pay, my treatments has to not only conform to the plan, but shows progress towards the plan.

    Part of the issues he found was I was out of shape, and he had me go on a treadmill, excercise bike, and a few other pieces of equipment at his office which could all be found at a gym. The normal session calls for me to go on the equipment for 45 minutes, and he interviews me and does some manipulations in his office, with the interview, and this last no more than 10 to 15 minutes each session.

    My insurer started paying, and I receive checks which I assigned to him, for treatments totalling $400 for each session, at two sessions a week, every week, and it comes to $3,000/month. I thought the bills were a bit high. One day I decided to stop and ask if the insurer ever thought of sending me to a gym, instead of paying him. This is when he told me about the health insurer audits.

    He tells me that each patient treated is subject ot an audit, and the insurer can find fault with the plan, or find his treatment ineffective, or NOT MEDICALLY necessary, and ask for a refund. I asked him if he was asked for refunds, and he said "in a few cases".

    What was my re-action??

    I told him that I trust him to come up with a plan satisfactory to me, and asked "if he was asked for a refund, by the insurer, would he STICK ME WITH THE BILL"?? He hesitated for a moment, and said "NO, I promise that if I offered an ineffective treatment plan, you won't be stuck with the bill".

    I told him that based on this promise, I will not be going to get a second professional opinion, but I told him that I would be ready to sue for malpractice if I ever hear from him that his treatment plan was invalidated.

    Now, I happen to tell this story to my boss, and she had a bad case of herniated disks going back years, and she's out of work at least 10 days a year due to this. She said she was once treated by another chiropractor, spent $180/session, going on over a year. Then a year later, BIG SURPRISE, the chiropractor asked her to pay several thousand dollars in chiroprator bills that the health insurer invalidated. Now this is the same insurer paying my chiropractor.

    I explained to her that I had a talk with my chiropractor, and he assured me that I would not be asked to cover bills invalidated by the health insurer, and I assured the guy I would sue for malpractice if that ever came to pass. She shook her head and explained she didn't think of that, and settled, and paid 50% of the bills.

    I am not passing judgment on your treatment with your patients, but it was my opinion, as I explained to my chiropractor, that I am relying on him to determine the medical necessity and effectiveness of my treatments, and if he proved to be wrong, I shouldn't have to go to bankruptcy court to get myself out of the mess he got me into.

    I agree with you, if I was your patient, not only would I not pay, but I would most likely sue if I was asked to pay bills for treatments found "medically unnecessary".

  5. #5
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    .... if I was your patient, not only would I not pay, but I would most likely sue if I was asked to pay bills for treatments found "medically unnecessary".
    Wouldn't that depend upon what the insurance company's definition of "medically unnecessary", and why it took two years for them to come to that conclusion?

    Example: Patient presents with a history of GI bleed, is complaining of burning/stomach pain after eating, and a positive at home test for blood in the stool. Doctor orders a very basic blood count (CBC) ....totally logical, right? Insurance company comes back a year later (after paying the claim), stating the CBC was "medically unnecessary". Why?...because the CBC results came back within normal limits. Isn't hindsight wonderful? Ridiculous.

    Obviously, OP did his/her homework by submitting treatment plans which supported the initial decision by UHC to authorize treatments. They then continued to pay for 22 visits. Now, 2 year down the road, they change their minds and demand their payment back? IMHO, it's disgusting.

  6. #6
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    Mar 2008
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    Quote Quoting lealea1005
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    Obviously, OP did his/her homework by submitting treatment plans which supported the initial decision by UHC to authorize treatments. They then continued to pay for 22 visits. Now, 2 year down the road, they change their minds and demand their payment back? IMHO, it's disgusting.
    Agree with you here.

    But based on my discussion with my chiropractor, as far as the time line goes, the insurer first pays it, then go through treatment procedures done at his office a year or two after the fact in an audit, and disqualifies those the insurer find unnecessary. It appears what my chiropractor told me about the audit procedures was in line with what the OP is saying.

    Now, then there an issue of where the patient stands in all of this??

    It seems health care providers would point to agreements they have patients sign where anytime some disagreement between the insurer and provider arises, the patient is held holding the bag, and MADE TO PAY. In the ridiculous case you cited, the poor patient is then called on to make the payment. I find this even more ridiculous.

    I myself was put in for collections by a hospital system after my insurer informed me and the state insurance department that the hospital bills were paid in full. The hospital claimed the bills were not paid in full and cited agreements I signed saying I pay what my insurer failed to pay. My insurer claims the payment were in line with an agreement they had with the hospital system.

    Think about it for a moment. Am I supposed to hire lawyers to review what agreements were made between the hospital and insurer???

    So I did some research, and found a NYS insurance law that prohibited providers from suing patients where procedures are covered under insurance plans. Also, under my plan, a patient only makes a co-pay of $50.00 to the hospital, and that's it. When I made my $50.00 check to the hospital, I marked down "payment in full" on the back.

    In answer to the collection efforts, I told them that state law prohibits providers suing patients where there is coverage, and it is up to them to fight it out with the insurer. Second, I pointed out that I marked "payment in full" on the check, and they accepted the check as payment in full.

    Payment in full to me does not mean I pay the max of $50.00 as called for under my plan, and cover any billing disputes between the insurer and provider.

    I'm mentioning this because many people I came across assumed that if they sign agreements with providers, they are stuck with the bills. In my case, my answer stopped the hospital system in it's tracks. They agreed that they cannot come after me after receiving my written letter, despite all the agreements they claimed I signed. I told them most of them were in violation of the state law anyway.

    I did not say this to my chiropractor, but if he was to sue me for bills that the insurer disqualifies, I would also point him to the same insurance law that says that he cannot sue me. I only told him I won't be paying it, and he agreed he won't ask me to.

    Ironically, my wife works for that same hospital system that sued me right now.

  7. #7
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    It seems health care providers would point to agreements they have patients sign where anytime some disagreement between the insurer and provider arises, the patient is held holding the bag, and MADE TO PAY. In the ridiculous case you cited, the poor patient is then called on to make the payment. I find this even more ridiculous.
    I would assume most laypeople find the case I cited ridiculous. Over the years I've seen many changes and learned a lot of "ridiculous" things occur when dealing with insurance company decisions. Let me assure you it's true, and happens more often than you may think. IMHO, if the provider jumps though all the required hoops to obtain approval/authorization/payment for treatment, and in hindsight a year or two down the road the insurance company reverses it's decision, the insurance company should eat the cost...not the patient....not the provider.

    I myself was put in for collections by a hospital system after my insurer informed me and the state insurance department that the hospital bills were paid in full. The hospital claimed the bills were not paid in full and cited agreements I signed saying I pay what my insurer failed to pay. My insurer claims the payment were in line with an agreement they had with the hospital system.
    If the hospital/Physician/facility had a contract with your insurance company, they must accept the amount the insurance company pays...the "reasonable and customary" amount.... as payment in full. Any agreements are for the amounts an insurance company (even contracted) deems "not covered" by your policy, any co-payments, co-insurance and/or deductibles. If a procedure is not covered by your policy then the provider may collect the amount. One example I can think of off the top of my head would be an "administrative physical" (one for work, school, etc.) or lab work required for a non covered service, such as cosmetic surgery.

    Second, I pointed out that I marked "payment in full" on the check, and they accepted the check as payment in full.
    Writing "paid in full" on your check does not relieve you of your responsibility to pay. Accepting a check with that notation does not obligate me to forgive the remainder of your account balance.

  8. #8
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    Mar 2008
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    Quote Quoting lealea1005
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    If the hospital/Physician/facility had a contract with your insurance company, they must accept the amount the insurance company pays...the "reasonable and customary" amount.... as payment in full. Any agreements are for the amounts an insurance company (even contracted) deems "not covered" by your policy, any co-payments, co-insurance and/or deductibles. If a procedure is not covered by your policy then the provider may collect the amount. One example I can think of off the top of my head would be an "administrative physical" (one for work, school, etc.) or lab work required for a non covered service, such as cosmetic surgery.

    Writing "paid in full" on your check does not relieve you of your responsibility to pay. Accepting a check with that notation does not obligate me to forgive the remainder of your account balance.
    You made some good points, and relating back to the OP's original issues, if the insurer approved his treatment plan, then disallowed it after an audit two years later, it is NOT something that a patient is automatically responsible for. By approving it originally, then even paying for it, the insurer acknowledged it is something they are covering.

    It woud appear the current disapproval is an issue between the insurer and provider, and the patient is in no way responsible.

    As an example, my chiropractor is having me use his on site gym, calling the sessions physical therapy, even though he had no PT's supervising me at all the whole time I'm excercising. Some years back, my wife had a severe back problem, her chiropractor suggested she take up swimming to build up here back muscles, and she paid a small membership fee at the "Y", and swam several times a week at no cost to her health plan. She paid a for a few sessions with her chiropractor.

    I have no beef with my chiropractor, except I find him billing my plan $400 per session using his gym equipment excessive, but I could see he has it broken down to a number of codes on the bills for each session. I told him I'm only going forward because my health insurance is paying for it, and he found it necessary. But I'm not about to shell out $400 to use his gym for an hour's time, unsupervised, if I was paying for it myself.

    In the back of my mind, I'm thinking if he get's audited, as he mentioned he might, and my $400/hour gym sessions get bounced, I'm not about to shell out for it, as I already pointed out to him it would be cheaper for me to join a gym, and maybe use a coach. His answer to that was he's got a pre-approval for my treatment, and a coach does not have medical training.

    For the moment, I would take him at his word that he is not going to bill me if my insurer disqualifies him. However, based on all the facts and the law, I can't see how he is going to then "bill me" for it later if he changes his mind.

  9. #9
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    Default Re: Preapproved, Paid, Now Insurance Wants Money Back

    As an example, my chiropractor is having me use his on site gym, calling the sessions physical therapy, even though he had no PT's supervising me at all the whole time I'm excercising. Some years back, my wife had a severe back problem, her chiropractor suggested she take up swimming to build up here back muscles, and she paid a small membership fee at the "Y", and swam several times a week at no cost to her health plan. She paid a for a few sessions with her chiropractor.

    I have no beef with my chiropractor, except I find him billing my plan $400 per session using his gym equipment excessive, but I could see he has it broken down to a number of codes on the bills for each session. I told him I'm only going forward because my health insurance is paying for it, and he found it necessary. But I'm not about to shell out $400 to use his gym for an hour's time, unsupervised, if I was paying for it myself.

    Honestly, I could see how the insurance company would find that suspect. Chiropractors seem to bill differently than MDs. I understand, from a Chiro friend, there are some states that require Chiros to do their own PT, but I would hope there was a standard of care regarding supervision during treatment. I'd be curious to see the codes being used.

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