United Health Care ripoff, misrepresentation, falsification of information, lied, refused, decnied, mislead, misinformed, falsification Atlanta Georgia

United healthcare has denied my claims of office visits which are six months old. They give the doctors a excuse that I have a primary insurance which I do not. I contact the insurance and they give me another story. Anything to deny claims. This company is a very poor healthcare choice. I have had it in several states and it is nothing more than like medicare. Doctors and companies need to spend more money and get better healthcare or just not offer it. The only thing united healthcare can do is get you in to see the doctor, you will be left holding the BILL.

White House TN

I have had United Healthcare for years and am slowly learning their rules. If you have not already cancelled your policy with them, don't. They are really the best company around with paying claims. This I learned from my child's pediatrician's office.

First, does your policy have a co-pay? Where you usually pay from $15 - $35 for the doctor's visit? If so, then any doctor visit (with exception, see below) is usually covered, less the copay amount.

If your policy does not have a co-pay, then annual exams are covered. However if you have a deductible that you have not met, you must pay your doctor in full and the amount goes towards the deductible. Therefore, the annual exam is "covered" but placed towards the deductible. Without a co-pay plan, any doctor visits are not paid by insurance until you have reached your deductible.

Now for the exception. If you make an appointment at a doctor's office, you must ask them "Are you in United Healthcare's network?", or check myuhc.com yourself. You can no longer ask the doctor "Do you take United Healthcare?" because all doctors "take" United Healthcare so they will say yes, and then bill the insurance company. If you have met your out-of-network deductible, the insurance company will pay the bill. If you have not met the out-of-network deductible (most people don't), the insurance company will not pay the out-of-network doctor, and you are liable for the bill. The amount goes towards your out-of-network deductible. This is how out-of-network doctors can get the entire fee for their services, rather than only the contracted rates that in-nework providers can charge. Remember, just because you went to your doctor last year, and they were in-network, does not mean they still are.

Either your doctor was out-of-network, or you do not have a co-pay plan and have not met the deductible.

By the way, with the co-pay plan, you usually do not get an EOB for a regular doctor's visit. After you pay the co-pay to your doctor, the billing is between your doctor and the insurance company.

Another note, if a doctor's office has bad accounting procedures and does not bill you or your insurance company within a certain amount of time (I think it's 6 months), it is too late for them to bill the insurance company. They cannot hold you liable for the bill because it is their fault the insurance company did not pay their claim. I believe this is stated in the doctor's contract with the insurance company.

Kelly -

I have worked in the medical insurance field for 10+ years, one thing you might want to check is the diagnosis code and CPT codes that were billed for that visit, what sometimes can happen is this:

Patient goes in for an annual visit, mentions to the Dr that they are having an issue with "Symptom A"

a couple of things could happen:

1) The Dr's office submits the claim with a "sick" diagnosis and a "well visit" (annual) CPT code, this is a claim mismatch, the claim will usually get denied.

2) the Dr's office submits the claim with a "sick" diagnosis and a "sick visit" CPT code, this would pay out under your office visit benefit but NOT your annual, because the insurance company thinks you went to the Dr for "Symptom A"

What should happen when you go in for your annual visit, is the Dr's office should bill both the Diagnosis and CPT codes as a "Well Visit" or annaul visit so its applied to your benefit correctly.

I know its been a while since you posted this, so hopefully its already resolved, but just in case, try calling the insurance company again or maybe the Dr's billing office....Good Luck