United Healthcare United Healthcare Denial of Benefits Internet

The following is an expression of my right to Free Speech, protected under the First Amendment of the Constitution of The United States of America, It is the opinion and property of the author and is for entertainment purposes. As such it should not be considered actionable by any parties mentioned herein.


Policyholders, BEWARE of this tactic.


My daughter suffered a muscular injury due to sports. Went to see our General Practitioner, an M.D., who diagnosed the injury and ordered physical therapy. UHC authorized 8 PT sessions. We used 3 as most of the therapy involved out patient exercises. My daughter raegrivated the injury several weeks ago and we went back to the therapist, who wanted to start seeing her 2x / wk. UHC authorized only 2 visits ( our original authorization for 8 visits had 'timed out').


I called UHC for an explanation of their denial of benefits (each family member has 40 physical therapy visits per calender year as a basic benefit), and was told by a level one representative that UHC submits such claims to the AMERICAN CHIROPRACTIC ASSOCIATION for approval, and based on the ACA's assessment, UHC was authorizing two visits.


I asked the rep, point blank, what the relationship was between United Healthcare and the American Chiropractic Association and what was the nature of the contract between them. I was told by the UHC rep that there was no contract between UHC and the ACA.


The answer to my next question was stunning...


I asked, "... so, am I to understand that a professional association, that has never examined my daughter and has no contact with either me or our doctor and has no contract with United Healthcare, has the power to supersede a medical doctor's direct orders?"


The answer was"yes".


After speaking with UHC, I started doing my homework. 


The American Chiropractic Association has enjoined in a class action against United Healthcare (www.erisaclaim.com/UHC_Complaint2.pdf) which alleges, among other things, 
" In addition to its improper recoupment activities, United, through its wholly 
owned subsidiary OptumHealth, Inc. (Optum), also engaged in improper actions, including 
denials of benefits, by application of flawed, manipulated and undisclosed policies designed to 
discourage and limit the provision of health care services, as described herein. In so doing, 
United has similarly violated ERISA. "


It seems odd that the ACA would take it upon itself to be an arbitrator, and take on the liability of superseding a Medical Doctor's orders when it is:


A) Suing UHC for denial of benefits contrary to  care plans, and ...


B)According to the ACA's own Policy Papers ( www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=117): 
 DIAGNOSIS - ACC STATEMENT
Resolved, that the House of Delegates endorse the ACC statement on Diagnosis: 
"A diagnosis is an expert opinion identifying the nature and cause of a patient's concern or complaint, and/or abnormal finding(s). It is essential to the ongoing process of reasoning used by the doctor of chiropractic in cooperation with the patient to direct, manage, and optimize the patient's health and well being. 
The process of arriving at a diagnosis by a doctor of chiropractic includes: obtaining pertinent patient history; conducting physical, neurological, orthopedic, and other appropriate examination procedures; ordering and interpreting specialized diagnostic imaging and /or laboratory tests as indicated by symptoms and/or clinical findings; and performing postural and functional biomechanical analysis to determine the presence of articular dysfunction and/or subluxation." 


If this is the Policy Position of the ACA, why would the ACA presume to pass judgment over another medical professional without taking the steps required of their own members?


IS this just a tactic being used by United Healthcare, in effect throwing the ACA 'under the bus' as an excuse to deny a basic benefit of the policy already paid for by we, the policy holders?


I am digging into this issue and ask any who read this and may have a similar situation to post on this thread.


Sincerely,
Mike 
Tucson, Az.