We are Internists that see patients in the office as well as in the hospital. We are finding 3 out of every 5 UHC claims are coming back requesting the medical records to process the claim. It doesn’t matter if it is an office visit or an in patient hospital visit. (thankfully we have found a new tool on their website to stay on top of these paper requests before they even get to us. Unfortunately it seems more requests for medical records end up on the UHC mail room floor than the ones that actually get to us).
Once we know they want the Med Recs we send them immediately. With UHC it seems you send the Med recs to UHC they forward them on to Optum. Optum then reviews, gives the ok, and then sends notice back to UHC to process and pay the claim. UHC pays the claim and all is right with the world. <—— That is the dream scenario.
(what actually happens)
– Med recs are sent to UHC
– UHC forwards to Optum and then that’s it.
– Many cases we will call after some time to find the claim status. We are usually told by UHC they do not have the med recs. We have uploaded them to their web site so we know for a fact they have them….
– We give them the ticket number and they eventually find it and tell you to call optum because Optum should have reviewed it. Then we get an image number from UHC to give to Optum.
– We call Optum and they say they don’t have the claims
_give Optum the UHC image number and they eventually find the claim and say oh yes we reviewed this and sent it back to UHC to process…. you need to call UHC.
– Call UHC back and start from scratch… we don’t have the med recs.
– After going around and around they finally say OK we will send the claim back for review give us 15-30 days to process.
– Working the rest of our AR lists we call back in another month or so and start at the beginning once again. Usually the final outcome is we get a denial for Timely Filing.
– NOT giving up we file an appeal as directed , faxing to the escalation unit… again we have proof they have received it.
– Another denial for TF
– After 2 appeals we are going in circles and wasting more time
*** Being out of network we do not have a provider advocate to help us. We have even tried to submit to the NYS insurance commissioner and been told UHC is not a NY company and they can not help us. Is anyone else having this problem or found a way to avoid this entire run around??????
Thank you