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  1. #4
    Join Date
    Mar 2008
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    1,995

    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".

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