Is there a way to file a complaint against UHC/ Optum BH?

Cavalier40

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138
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Stuart, FL Sailfish Chapter
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I run the billing department for a Substance Abuse PHP facility and a free standing detox facility. (2 separate facilities) UHC/ Optum BH has pretty much put the entire MH/SA industry under PNI investigations. I am no so much bothered by that because we have top notch compliance, but what is bothering me is the horrible way our facilities are being treated and I feel as if we are being sabotaged by UHC.

First thing is that both facilities are under PNI investigation. They started as retrospective reviews. We complied with the requests and have been constantly sending records for several months to the point I had to hire an additional person just to keep up. Without an outcome of the review and without explanation, PNI put both facilities under pre payment audit. We were not told of the the reasons or of any deficiencies in our charting, however in one of my few interactions with our auditor, I was advised that something negative was found during the retrospective review that caused that decision. She would not tell me what it was. However since we have been put on prepayment audit, we have passed over 90% of our prepayment reviews and have gotten paid......over 120 days later. Now the auditor will not answer my calls or my emails.

Now they are pulling a stunt to where they are claiming they did not receive our records. They have shortened the time to process records requests from 45 business days to 45 calendar days (which is actually less than 30 days since we usually get correspondence 15 to 20 days after it is dated), and they are not sending remittance in a timely manner as well. I feel this is an attempt to forcibly run out the clock so that we do not pass the pre payment audit. We fax all of our records with the proper cover sheet and have verification of receipt.

I feel as if I am at my wits end and I want to report them to somebody. Will a complaint to URAC actually do anything? Since all UHC plans are ERISA, can my state insurance commissioner do anything? Any advice on how to stop them from doing this would be helpful.
 

glanter

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Charleston, SC
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We're having similar issues on the surgical side of things

Just wondering if anyone else is getting claims review through Optum that are completely inaccurate? Procedures that are clearly in the operative notes denied, separate procedures bundled inappropriately, procedures denied as "size of defect" not documented although its right in the operative text?

I think this is a training and education issue within Optum/UHC. I wish AAPC would take up this issue and try to help us resolve. It's very frustrating that they are obviously using untrained eyes to review our claims and we have no recourse.

Gail
 
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