Cavalier40
Guest
I am having an issue with UBH/Optum.
Basically if the facility treatment does not require UR/Prior auth, then we will get a medical records request for every claim submitted. I have confirmed that we are not under audit, and when we do have an auth number, we have no problem getting paid. I feel this is a malicious obfuscation of paying claims and a violation of the minimum necessary standard of HIPAA.
We have been complying with the requests, however the records never seem to get attached to the claims, or we are told they are sent to the wrong address. (even though we send to the address on the correspondence) When they do get the records, we are told they are incomplete, or they were not received timely. Sometimes we are told that medical necessity is not met, but we are never given an explanation of what standard is not met and where the records are deficient.
The only answer I hear from the off shore call center is that our per diem rate is too high. I think this is incorrect since we are out of network and do not accept assignment, the vast majority of the claims are sent to Multiplan for repricing.
This is wrong to the point of being criminal, however since all UHC plans are self funded, they hide behind ERISA.
Does anyone have any insight or solution? That would be greatly appreciated.
Basically if the facility treatment does not require UR/Prior auth, then we will get a medical records request for every claim submitted. I have confirmed that we are not under audit, and when we do have an auth number, we have no problem getting paid. I feel this is a malicious obfuscation of paying claims and a violation of the minimum necessary standard of HIPAA.
We have been complying with the requests, however the records never seem to get attached to the claims, or we are told they are sent to the wrong address. (even though we send to the address on the correspondence) When they do get the records, we are told they are incomplete, or they were not received timely. Sometimes we are told that medical necessity is not met, but we are never given an explanation of what standard is not met and where the records are deficient.
The only answer I hear from the off shore call center is that our per diem rate is too high. I think this is incorrect since we are out of network and do not accept assignment, the vast majority of the claims are sent to Multiplan for repricing.
This is wrong to the point of being criminal, however since all UHC plans are self funded, they hide behind ERISA.
Does anyone have any insight or solution? That would be greatly appreciated.