Wiki UHC MEDICAlL RECORDS

[klapetri@ilovemygyn.com]

Hi,

We've been encountering multiple UHC claims that are either pending or denied due to medical record requirements.
Although we are uploading the necessary documentation through the UHC portal, some claims are still being denied for "unsupported documentation," while others are only partially reimbursed.
In many cases, after contacting UHC, the claims are reprocessed and paid. However, this ongoing issue is significantly impacting our cash flow.
Does anyone have insight or suggestions on how to address this more effectively?

 

[catherinetinkey@entmedicalservices.org]

We have been dealing with this for a couple years now. Optum (UnitedHealth group is the parent company) is now doing claims reviews for our local BC/BS and other companies as well. It appears to be quite the monopoly. We review all criteria set forth by the insurance plans before our providers ever schedule any procedures and let the patient know that their insurance company will or will not allow the procedure. The patient is informed regarding the criteria is their choice whether to proceed or not . I also find it very ironic that Optum financial, another of their divisions sends us emails for low interest loans to keep a steady cash flow. Optum's full-year revenues in 2024 were $253 billion, with a 12% increase year-over-year. Read the criteria and CPT descriptions on every thing you do make sure they are documented in the note. It is all very time consuming and the insurance companies are banking on providers that do not have the staff to fight all their denials, it is one big stall tactic to keep their money in the bank. The US has a physician and nursing shortage, all of the decline in reimbursement is going to cause cuts, it will not help this situation at all.

 

[andersona1229]

UHC pended all of my company's claims for six years, requesting medical records for each one; even after we complied with everything they asked, they kept us on prepayment review. We're an independent laboratory with a high volume and only have access to the req/results. They found something to complain about, even after we made all the changes they wanted. The most ridiculous one was when they told us that we couldn't use POS 81...even though that's the laboratory POS. I'm not sure of the specifics of how we resolved the issue, but I do know that a strongly worded legal letter was involved. No documentation was ever good enough either.

Everyone is transitioning to using Optum for record reviews. Centene plans have been working on it for a few years now and I'm just waiting for them to try to pull this crap too.

The only advice I have is to ride it out and push back hard if necessary.