Complaint Letter sent on to my State Senators

[Guest guest]

What follows is an email with attachments that I sent out today to a couple of

Iowa State Legislators today. I pass this along in hope that someone might read

it and decide they have similar issues and decide to take or make a stand.

Dawn/

Hopefully as the Iowa legislative session draws to a close, I will be able to

catch up with one or both of you to further learn about the legislative process

and determine where the bills that I asked to be sponsored derailed. While I am

not upset by that fact, I do want to understand more about the legislative

process so that I can know why something that I consider to be fair, didn’t

get very far into the session. I am not actively involved in

politics/government and did not work with anyone else on my issues, so it may

just be that these items weren’t very well understood or didn’t have broad

based support.

Dawn, the last time you and I spoke, we talked about problems that healthcare

providers have with insurance company’s that verify insurance coverage and

indicate preauthorization of services are not required. Then, after we commence

billing the insurance company, they deny benefits indicating that we didn’t

preauthorize services. Below (in black text) is an attempt by one of my staff

members to educate a client of ours (a provider of healthcare services) on what

they have to do for each patient of this particular insurance company (United

Healthcare). My staff member spent OVER an hour and a half yesterday morning

(most of it on hold) waiting to get through to the appropriate people to find

out why our client’s claim was denied and then documenting everything for

their/our benefit. I should point out that this client is a not for profit

501©3 entity that provides occupational therapy services to treat children

with problems that aren’t being treated by any other organization(s). They

rely on all sources of revenue to keep their doors open every month (grants,

donations and insurance/patient payments) and this predicament causes them a

great deal of headache/heartache.

I want to point out a couple of things with the attached documentation:

The attached explanation of benefits from United Healthcare indicates that

services were never preauthorized by the provider.

Due to being burned on several occasions by insurance companies, this provider

adopted a policy that patients have to verify their own coverage. They handed

page 2 of this attachment to their patient prior to commencing treatment and

explained what the insured would need to do in order to verify benefits. I

might add that the provider got tired of being on hold so long with insurance

companies verifying benefits that passing this off to the patient/insured just

made sense.

As you can see from the attached form that was completed by the patient/insured,

they were told by Marilyn at UHC that preauthorization of services was not

required.

Page 3 of this attachment is a copy of the patient’s insurance card. Please

note that there is no reference to A.C.N. or OptumHealth.

After the patient completed their call, from the not for profit Clinic

called United Healthcare to double check the information provided by the

patient.

The attached explanation of benefits indicates that the provider of service did

not provide necessary documentation to A.C.N. Group-again, please note that

A.C.N. was not referenced in phone calls by the patient and provider.

Additionally, there is nothing on the patient’s insurance card that indicates

this is required.

This particular client is not being handled any differently than other therapy

providers that we have spoken with in the way United Healthcare is processing

their claims. Other clients and other therapy clinics around the state of Iowa

run into this very same problem; as well as other clients of ours that have

practices outside the state of Iowa (we bill for 80 clinic locations in 22

states). While some geographic areas in Iowa may have a huge number of patients

under a United Healthcare policy, other areas may only see one patient a year.

The point here is that providers shouldn’t have to run through extra hoops for

a company like United Healthcare to get paid for services that were rendered in

good faith. Also, I attended an Iowa Physical Therapy Association Conference in

the Spring of 2009 and remember hearing a United Healthcare presenter state that

A.C.N. has not been an active subsidiary for United Healthcare since 2006 or 7

due to some legal issues (or something like this). However, as you review the

attached explanation of benefits, the denial clearly states that the provider of

service did not obtain preauthorization from them (that is not exactly what the

denial code states, but that is the message provided when we called to ask what

is required to be paid).

The good news for our provider is that they will ultimately get paid BECAUSE the

patient was involved in the verification process. I know many other clients of

ours that aren’t so lucky. This is due to the fact that

UHC/A.C.N./OptumHealth will take a stance of no preauthorization, no payment.

Finally, my staff member spent over an hour on the phone trying to get to the

appropriate personnel at United Healthcare to determine WHY the claim was

denied. Additionally, the patient and provider’s office staff also spent time

verifying coverage. Services were provided in good faith and payment of service

was denied. In addition to the approximate 1 hour of treatment time, I would

estimate another 2+ hours have been spent chasing this denial. Providers should

not have to wait this long to obtain information and get paid on a claim. It is

outrageous that insurance companies like United Healthcare are allowed to do

business like this in the state of Iowa. I want to point out that I know our

clients experience similar response times and other providers around the state

have professed the same results. I suspect most of them do not take the time to

report the problem/abuse.

If your schedule permits, I would like to meet and discuss this topic further,

Jim <///><

:

The attached United Healthcare (UH) EOB dated 03-05-10 indicates a denial of

" ACN group did not receive from the health care provider the clinical

information necessary to establish medical appropriateness. Please refer to

your plan summary... " Our past experience with ACN is that they require

notification in advance of treatment or within a certain number of days after

treatment has started. ACN is now known as OptumHealth.

While it is not RMS' responsibility to verify benefits and eligibility, we have

had numerous clients who have experienced many issues with UH similar to this,

and with other insurance companies using ACN. So, as a professional courtesy, I

called United Healthcare to clarify the denial and to try to get the information

you need so that you know when you verify insurance you have what you need to

determine if you can reasonably expect the claim to be paid.

After numerous phone calls and being on hold for quite some time, I was able to

reach a customer service representative, Maureen, who said that your patient has

been eligible since 04-01-2008 and covered under Untied Healthcare Choice Plus

Plan as of 01-01-10. No lifetime benefit max. The benefit for OT coverage is

short term, with expected treatment no more than 2 months after start of

treatment, limited to 20 visits per calendar year. In-network, there is a $20

co-pay and claims are paid at 100%. If out of network, claims are paid at 70%

with an $800.00 annual deductible. In addition, Maureen said that a clinical

submission form should have been mailed or faxed to OptumHealth and they do not

show one was received. You can call OptumHealth at the number below to ask

about obtaining the form, or see the instructions below to get on their website.

Please note that in previous dealings with a number of different UH products,

RMS has been told that providers need to be in network separately with each UH

product. That means that your clinic must apply to be in network for United

Healthcare AND OptumHealth. Unfortunately, most UH insurance cards do not

clearly indicate what type of UH product is involved, so RMS strongly recommends

that you call and verify insurance on each and every patient with UH coverage.

Here's, hopefully, all the information you need to do that:

TO VERIFY UNITED HEALTHCARE BENEFITS AND ELIGIBILITY: Note that the patient's

insurance card will show no indication of ACN (now know as OptumHealth)

involvement and may not indicate the type of UH product.

UH phone number for providers:

You need: the clinic's tax ID number, the patient's ID number, and the

patient's date of birth.

To bypass the automated system (recommended because it doesn't give you all the

information you need) and talk to a customer service rep: Listen to the choices

and choose " Other services. " Listen to some more choices and choose, " Customer

Service. "

After verifying general coverage, be sure to ask specifically if Occupational

Therapy services are covered AND if ACN, (now know as OptumHealth, is involved.

If the answer is yes, then ...

OptumHealth Care Solutions Physical Health: Phone: , Fax:

Website: http://myoptumhealthphysicalhealth.com/

You can set up a Provider ID and password in order to access items on this

website. Please contact OptumHealth at their telephone number for assistance in

doing this. I viewed the Operations Manual and on page 10 under, Clinical

Submission Process Summary, it states, " The provider is required to submit a

Patient Summary form when treatment has been initiated or continuing care is

expected. " Maureen called the form needed a " Clinical Submission Form. " I

don't know if there are two separate forms or it is the same form, but called a

different name since ACN changed to OptumHealth. I was not able to view the

Forms, but once you get setup on the website, you will be able to access those.

Hope this helps.

Jim <///><

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