Issues with payment from Harvard Pilgrim Health Care and United Health Care


Stow, MA
Best answers
I work for a very small practice that bills out for acupuncture and medical nutritional therapy.

We are having two issues that are not getting resolved.

For over a month Harvard Pilgrim Health Care has, admittedly, not had our provider appear as if he is not credentialed in their system. All claims are being denied. What was supposed to be resolved over a few days is now about a month.

The one entity I have found in Massachusetts that, although it is meant for consumer complaints about insurance will take provider complaints, is at an 8 month back up.

The second issue started well over a year ago. A patient that has insurance with Harvard Pilgrim Health Care that is paid out by United Health Care had been seen and numerous visits were paid out by insurance. Nearly a year later payment was taken back on many claims. The reason for the adjustments in most cases does not make sense. Ex. same cpt code, DOS within same month and visit was paid as out of network and then adjusted as it was in network. One claim paid a few cents more than first amount and second claim payment was reduced by about 50%. There are many other issues. We are left with endless adjustments to claims, it being unclear as what the final payment and patient responsibility is and continued promises that it will be addressed.

Provider wants to bill client but with unclear payments and adjustments I have told him we can't as we could end up doing balance billing. Our local rep is at times non responsive. Questions about each reason given for adjustments that were provided in January have not been answered.

Calling United Health Care gets no results and there is an unusually high disconnection rate when inquiring about these claims.

Any ideas?

Thank You,