UHC FUBAR

[Welcome Industry Radar readers!]

Take one claim, file it with a carrier, then wait.

Three months later the claim is processed, and denied.

No problem. It wasn't our claim. It should have been denied.

But wait!

If it wasn't our claim, why did it show up in our file?

Good question.

On 9/4/08 some guy named Edward Vineyard visited Dr. Ohno. (Names changed to protect the innocent).

Dr. Ohno's office filed Edward's claim with United HealthCare.

OK so far, except . . .

We don't know Edward Vineyard, he is not a dependent of ours, and no one in our family have ever seen Dr. Ohno.

The claim was processed, under our policy number, by UHC on 12/5/08 and denied. Code R7.

What is R7 you ask?

Code R7: According To Our Records, This Dependent Has Not Been Enrolled For coverage. Therefore, We Are Unable To Provide Benefits.

Other than the mysterious claimant and doc, no problem.

So we called UHC and alerted them to the claim in question.

No problem (we were told). The claim would be investigated and removed from our account.

A month later the claim is still showing, but still denied.

Then . . .

A new claim appears.

Same patient, same doc, new claim. Incurred 1/15/09, processed 1/30/09 and paid.

So . . . we call UHC again.

They have no idea why the old claim is still showing, nor why the new claim was paid.

We are to check back with them in a week.

Today I checked our account.

The claim from 9/4/08, originally processed on 12/5/08 and denied, has been re-processed on 2/2/09 . . . and paid.

So . . . I call UHC and get the run around.

I ask for a supervisor.

None are available.

No problem, I will hold.

You can't do that. We were told yesterday not to put anyone on hold.

Goodbye.

I called back, went through the phone prompts, and spoke to Mary. This time rather than telling my issue, I asked to be connected directly to a supervisor.

Two minutes later I had Hannah, a supervisor.

I explained the situation and then asked why a claim that was challenged two months ago was reprocessed and paid.

Hannah had no answer.

Then I dropped a bomb.

We have talked with Dr. Ohno's office and were told the name of the patient, that he was covered by UHC (but under a different number) AND that Dr. Ohno's office was paid on the 9/4/08 claim before it was processed by UHC under our policy number.

(This is a clear violation of HIPAA by the doctor's office).

The UHC response?

They were quite upset that Dr. Ohno was paid twice. I was told they would contact him and get a refund for overpayment.

Oh, and this.

The supervisor promised to get back to me in 48 hours with an explanation.

This is a minor claim. Less than $1,000. Including the reprocessed claim, UHC has paid around $370 and charged it against our account.

If they can't handle small claims, what happens on a big claim?

FUBAR.