Medical Insurance claim denied by UHC?

My husband added me to his medical policy after we got married. Last year I started getting sick and look at the united health care directory for the list of Physician. I found a nearby doctor's office near my house and started getting treatment from this physician. The doctor usually get my insurance card and charge me a co-pay of $30 for like 4 times in 6 months series. After four months of my last treatment I received a bill from the doctor's office for $500 because the insurance denied my claim. The insurance said the doctor is out of network the reason why the claim is denied. I feel really devastated because why would the doctor accept my co-pay thinking they are part of the network. The doctor's office address is in the network book however the doctor's name is not written in there. I was wondering if im liable for that amount considering that the doctor make be believe they are part of the network and that the address is clearly published in the United health care in network book. Please help on the best option for me to do...any suggestions are welcome. Thank you in advance.

So far you've gotten some pretty good advice. It does sound as though you have an issue that may be resolved with an appeal. I will explain this in just a moment, and tell you what to do. First you need to be aware of a couple of things as a consumer, and an insured member. It is our responsibility as consumers to be aware of the products and services we pay for, to ensure that we get the right thing, and that it proves useful in the fashion we so desire. Having said that, as an insured member, you must be aware of the insurance product you are using when you go see a physician, or enter a facility for diagnosis or treatment. It is your knowledge of your own insurance that will assist you to keep unfortunate things from happening. Now, if your physician wants a "co-pay" or set fee each time you see him or her, it is most likely managed care. Managed care is not like traditional fee-for-service, or indemnity health insurance. You are not allowed to see anyone outside of the network for any reason, other than a life threatening emergency. It is up to you to make sure who it is you are seeing, to enroll under the correct Primary Care Physician within your network, and always see them before going to a specialist. As you are experiencing, if you forego this fundamental step in the process, you will suffer for it. That is not to say that there cannot be a positive outcome from this situation. This is how I would proceed:

Obtain information concerning your specific insurance policy, and make certain that the provider in question was indeed a participating member with UHC's network on the date services were rendered to you. This information can be obtained directly from UHC by simply calling the telephone number listed on your membership ID card.

If the doctor is NOT a member of the network, tell the representative that you are requesting an appeal of the denied claim. If they ask why, simply state that it was your understanding that the doctor was in network, and also, it is your right to appeal any claim.

If the doctor WAS, and/or still is, in network, ask to have the claim reconsidered immediately since the denial was in error. If the representative can verify that there was indeed an error on the part of the insurance company in how it handled the claim, they can choose to correct the error without you having to go through an appeals process. This is not always the case, but is a general rule. However, they will not do it if you don't ask.

When you are faced with the doctor being out of network, it is then up to you to come up with objective (factual) data to present your case, that you thought he or she was in network at the time. Gather any receipts that would prove, or state the fact that you made a "co-pay" or a "co-insurance" payment. There is a big difference in these terms. Co-pay refers to managed care, and co-insurance refers to indemnity coverage.

Any EOB's (Explanation Of Benefits) that would indicate that the doctor was in network would also be helpful. Has anyone else in your family seen this physician and gotten their claim paid? This could indicate the error, and could then be found on an EOB.

You must prove by whatever means you have at you disposal that you were led to believe that the doctor was in network at the time. It's not important to stress what is right, only what you can prove with documentation. It is really up to UHC at that point.

Good luck. Please let me know how it turns out. I keep a blog at:

http://www.askmrknight.com

It deals with insurance and appeals issues. Hope I was helpful to you.

First of all, do not ever rely on a printed directory as your main source of information. A provider network changes frequently, and a directory booklet could be out of date the day after its printed.

*Always* confirm the status of a physician on your insurer's website or by calling the insurer. Those sources are updated as changes are made, so they are far more reliable than a printed directory.

Also, the fact that the doctor's address is listed in the network booklet is meaningless...you have to verify the specific doctor's name at the specific location you're seeing him at.

Ultimately, from the insurance company's perspective, its your responsibility to confirm the network status of a provider. You can try to appeal the claim with UHC, but I'm not sure how much luck you'd have. (Especially since you said that the doctor's name isn't even in your directory.) Please note that if UHC decides to pay those past claims on appeal, they will likely stipulate that it is a one-time deal, and no future claims from that doctor would be processed as in-network.

I think you may have slightly better odds of getting somewhere with the doctor's office. You could try to negotiate your bill with them, and try to make the argument that they didn't tell you that doctor wasn't a network doctor. (Note - the doctor's office technically didn't do anything wrong and has the right to bill you for the full amount. But, you might be able to play the sympathy card with them and work out a deal.)

And for future reference, always, always, always verify both the name and location of the doctor in a current source...not a print directory! (Print directories are intended to be an example, not the final word...always verify with an updated source.)

Good luck!

That is an unfortunate situation. You may be able to get either the Doctor's office or the insurance company to give you relief in an appeal. Call your Doctor's office first and see if maybe they can help you out because of your past misunderstanding and then if they are unable to then you may want to try to send in an appeal to UHC.

First, just because 1 doctor in an office is in network with a certain insurance company doesn't mean every dr at that office is--they each can decide which insurance companies they'd like to participate with---just a note for future reference.

I would suggest appealing with your insurance company-you can do this over the phone with a representative or in writing. Just explain the situation and ask for an exception.

You can also talk to the drs office since they took the copay and led you to believe they were in network and see if they'll work out some sort of discounted rate.

i've been in your shoes before...you can fight this. some times insurance companies deny claims just so they don't have to pay.but if you fight it they usually pay...call the doctor's office & find out how long they have been out of network, if they were in network & changed status to out of network they should have told you when you showed up for treatment..if they state they are still in network call the insurance company & demand to speak to a claims manager & you want to file an appeal..good luck

Absolutely call the doctor's off first and see what the deal is. I have had them code something wrong, like put the wrong dr.'s name in, and had a claim denied. The office fixed the problem very cheerfully, and then the claim went through.

The second step is to call the insurance company and try to work it out with them. Again, mistakes happen all of the time. The fact that you used to be covered, and now aren't, makes me suspect an error.

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