United Health Care
Paying 50% Of Bill Instead Of 20%Mar 08 2012
My 3 year old son had surgery scheduled. I called UHC the morning of the surgery to pre-certify. They told me the provider needs to pre-certify. I called provider who told me they already called to pre-certify and were told it wasn't needed. The surgery was a success. Then the explanation of benefits comes in the mail. It shows that they are going to pay 50% and I have to pay 50% because a pre-certification was not done (my coverage is 80/20). I called and explained the certification process I went through. They said "no, It's the employee who must certify" and we have no record of your call. I told them I called and was told the provider needed to pre-certify and have cell phone records to prove it. They said to send all the information to an appeals board. So I did. I call 30 days later after hearing nothing and they said "were sorry it went to the wrong place". I read them the address they gave me and the rep said it was correct. So they had to resubmit and take another 30 days to review. Meanwhile I'm getting calls from the provider for the money due. I call the provider and they allow me to wait on payment. After 30 more days I call UHC and they say the appeal was denied and that the provider needed to pre-certify. I explained both myself and the provider called to pre-cerity and they told us it wasn't needed. She said "I will forward you to the rapid resolution center". The resolution center heard my complaint, reviewed it, and said the provider was paid correctly at 50% for not pre-certifying. I said, ok, that's between you and them, but why do I have to pay 50% when my plan only states I owe 20%? If It's the providers fault then It's out of my hand. She said I see, let me take 5 days to look into this and call you back. Four days later I received a call back from the resolution center and they said "you owe 50%" to the provider and if you want you can call the provider and get them to lower their charge. I call the provider and they say the EOB says the patient owes 50% so we want our 50%. So in the end, UHC lied about pre-certification (both the provider and I have proof) and they have consistently delayed and refused to pay. They get a discount by only having to pay 50% to the provider where as instead of me paying 20% I'm now going to have to pay 50%. I'm being penalized for the provider not per-certifying (which the provider has computer records that they did pre-certify and I called them the morning of the surgery and verified this).