# United Healthcare/Optum Claims Review



## glanter

Just wondering if anyone else is getting claims reviewed through Optum that are completely inaccurate?  Procedures that are clearly in the operative notes denied, separate procedures bundled inappropriately, procedures denied as "size of defect" not documented although its right in the operative text?    I've tried to call and speak with someone on multiple occasions because these folks just don't seem to know how to apply the rules but can't seem to get anywhere.  They are so unprofessional!

G. Lanter


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## mgarciaManagement

Hi G. Lanter,

I recently dealt with UHC/Optum denying a claim stating we were at our 2nd level of appeal and nothing else can be done.  Optum would not budge and told me I needed to call UHC; did that.  UHC said I needed to call Optum.  I stopped it right there and asked them to put a Director on the phone and that I was not going to play that game.  (I've been in the medical industry for 25 years and not about to waste my time.)  UHC advised me to speak with our Claim Advocate Representative.  WHAT?  Ok, so, 25 years and now we have Claims Advocates; where have I been??   

I spoke with my Claims Advocate and during our conversation I realized my collector never sent an appeal.  All we ever did was respond to Optum's request for medical records to process the claim to begin with.  We had to submit records twice due to no response, but Optum turned it into a 2nd level of appeal.  I have a few words to describe this scenario.  Anyway, my Claims Advocate suggested that we submit a corrected claim via the UHC/Optum Link website with additional documentation.  I did just that, which took 5 minutes and in 10 days the claim was reprocessed and considered payable.  

It may not be exactly what they are telling you that is wrong with the notes or claim.  Try sending a corrected claim via the site with additional documentation.  Maybe call customer service or your provider rep and ask for the contact information for you Claims Advocate.  The Claims Advocate did tell me that they hear it a lot from practices of what Optum is doing.  This lady was on our side.   

Hope this helps.


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## glanter

*Uhc inappropriate denials*

Thanks for the feedback.  It's just so frustrating and time consuming. I too have been doing this a long time....since the late 80's.   I've spoken to so many people at UHC lately and we've recently been assigned a new advocate in whom I have absolutely no confidence after just one interaction.  I think the answer may be to cancel with UHC due to breach of contract and move on.  

G. Lanter


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## tward01

I have gone around and around with Optum and this issue.  They ask for medical records to include labs, radiology, etc.  I sent the entire medical record for a patient (she had only been seen 2 times and had an MRI) in chronological order and Optum looked at the first page and said our codes were not supported because we didn't send what was asked of us.  I sent it again via Link, and it was ignored, I faxed it to them and it was ignored.  Finally I got a nasty rep on the phone after months of back & forth with them and UHC pointing fingers at each other and he said they denied it and we can send all the records we want but until we send an official appeal with the phrase "we hereby appeal your denial" on it, they were going to deny it as a duplicate.  I told him it wasn't fair to have to appeal something they clearly ignored.  I asked for a supervisor and he said "no, you can't talk to them, they don't talk to customers".  I nearly flipped!  I told him I wanted a supervisor immediately and he said he could maybe put in a request and someone would call 24-48 hours later and I insisted I speak to one now.  He said, "well it's not like they're just going to come over here and pick up my phone!".  I suggested that he could transfer me and he refused so I said to make the request.  He asked my hours at work and then said "provider wants you to overturn decision even though she refuses to appeal our denial".  I told him he was not to write that since it was a lie and he said "well what do YOU want me to say then, huh?"  I told him that I'd like to discuss why they are refusing to review the information provided to them and only looking at one date of service and not the full packet sent to them.  He says that's what he wrote.  3 days later (outside of 48 hours) I received a voice mail at 7pm at night (outside of the 7:45-4:45 EST I gave him) from the same person, "Ron", claiming to be the supervisor and he said "this was denied so if you don't appeal, there is nothing we can do.  THANKS!"  I appealed it and notified our provider rep.  She was, unfortunately, not surprised at the treatment I received.  This is just one of the many similar cases I have had with them and we never seem to get their supposed denials to even appeal.  The one's I do get, I just go straight to appeal now because talking to them is useless!  It is so frustrating, but I'm glad to hear it's not just me!


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## RebeccaB

They are the worst...UHC/Optum has denied a claim since last year for a laparoscopic cystectomy that we billed with the unlisted code 51999 since there is no specific CPT code for this..they have insisted that this is billed incorrectly that the claim should be submitted with the open cystectomy code even though it wasn't an open procedure...UGHHH!!!!
I cannot figure out what their thought process is...no common sense...zero..none..they should not be allowed to operate as they do

Rebecca
Urology Associates


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## MGUPTE

glanter said:


> Just wondering if anyone else is getting claims reviewed through Optum that are completely inaccurate?  Procedures that are clearly in the operative notes denied, separate procedures bundled inappropriately, procedures denied as "size of defect" not documented although its right in the operative text?    I've tried to call and speak with someone on multiple occasions because these folks just don't seem to know how to apply the rules but can't seem to get anywhere.  They are so unprofessional!
> 
> G. Lanter


Stay up to date on information and protect yourself well. OptumCoding which is another part of OptumHealth just sent me 3 code books without receiving payment and did not tell me my order was processed or being sent, I only ordered one book, they refused to do a refund and then were hounding me for payment. I wound up over-paying and was being called by debt collectors... My bank then found confirmation of fraud but I have no proof because my bank did it all discreetly. All I can say is what I have found for past legal cases against Optum:

There are lawsuits against Optum and its subsidiaries. Going back to like 2007, this is from dates between 2012-2016: This is an example of medicaid but I have seen many other lawsuits as well:

Former OptumHealth senior fraud investigator, alleges that she discovered $4 million in potential Medicaid billing errors by OptumHealth. She said the company told her to keep quiet about it, and that she was fired for reporting concerns about Medicaid fraud to the Attorney General’s Office.

The suit also reveals new details about criminal charges against a former OptumHealth employee accused of falsifying company records.

The former fraud investigator first sued OptumHealth in May 2012. But the case remained under a court-ordered seal for more than three years at the request of the state Attorney General’s Office as it investigated her complaint. She filed an amended suit against the company March 18 under the Fraud Against Taxpayers Act.



			https://www.santafenewmexican.com/news/local_news/optumhealth-accused-of-fraud-in-three-lawsuits/article_63b6b337-fc01-5c89-a828-c573977fcdb2.html


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## MGUPTE

2021, For the second time in one month, the U.S. Justice Department has sued UnitedHealth Group for wrongfully obtaining over $1 billion from Medicare



			https://www.whistleblowerattorneys.com/blog/whistleblower-unitedhealth-medicare-advantage-fraud


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## ADD1919

MGUPTE said:


> Stay up to date on information and protect yourself well. OptumCoding which is another part of OptumHealth just sent me 3 code books without receiving payment and did not tell me my order was processed or being sent, I only ordered one book, they refused to do a refund and then were hounding me for payment. I wound up over-paying and was being called by debt collectors... My bank then found confirmation of fraud but I have no proof because my bank did it all discreetly. All I can say is what I have found for past legal cases against Optum:
> 
> There are lawsuits against Optum and its subsidiaries. Going back to like 2007, this is from dates between 2012-2016: This is an example of medicaid but I have seen many other lawsuits as well:
> 
> Former OptumHealth senior fraud investigator, alleges that she discovered $4 million in potential Medicaid billing errors by OptumHealth. She said the company told her to keep quiet about it, and that she was fired for reporting concerns about Medicaid fraud to the Attorney General’s Office.
> 
> The suit also reveals new details about criminal charges against a former OptumHealth employee accused of falsifying company records.
> 
> The former fraud investigator first sued OptumHealth in May 2012. But the case remained under a court-ordered seal for more than three years at the request of the state Attorney General’s Office as it investigated her complaint. She filed an amended suit against the company March 18 under the Fraud Against Taxpayers Act.
> 
> 
> 
> https://www.santafenewmexican.com/news/local_news/optumhealth-accused-of-fraud-in-three-lawsuits/article_63b6b337-fc01-5c89-a828-c573977fcdb2.html


ALL THE TIME!  It is the most frustrating thing.  Even working with MSSNY in NYS to try to resolve this and they aren't getting very far either!  SO very frustrating!


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## ADD1919

glanter said:


> *Uhc inappropriate denials*
> 
> Thanks for the feedback.  It's just so frustrating and time consuming. I too have been doing this a long time....since the late 80's.   I've spoken to so many people at UHC lately and we've recently been assigned a new advocate in whom I have absolutely no confidence after just one interaction.  I think the answer may be to cancel with UHC due to breach of contract and move on.
> 
> G. Lanter


Problem is OPTUM is also "reviwing" notes for numerous other ins companies now... they are teaching them how to steal from providers!


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## Sarahlukkarila

Has Optum and UHC started with POS denials for anyone else on this blog


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## camillecoder@hotmail.com

I would love to see a class action lawsuit from physicians and hospitals.  Around here UHC/Optum is known as Voldemort.  Ludicrous denials.  Ridiculous games.  Worthless customer service reps and provider reps. Deny, delay, defend.  UHC knows the game and they do it well.


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## SSummCCH

camillecoder@hotmail.com said:


> I would love to see a class action lawsuit from physicians and hospitals.  Around here UHC/Optum is known as Voldemort.  Ludicrous denials.  Ridiculous games.  Worthless customer service reps and provider reps. Deny, delay, defend.  UHC knows the game and they do it well.


I totally agree.  The hoops we jump through is crazy.  I know that many providers in our surrounding area do not have a contract with UHC.  I would love to go in that direction but I doubt that will happen.  They will authorize a payment and then come back years later and "gee, after further review, we want our money back." UHC is my nightmare.


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## danachock

UHC is a "complete nightmare" in my opinion. I will often jump over those denials while working them because the denial reasons are so inaccurate. Those UHC denials are not a normal like amount of time for denial (I am unsure my allocated time but anytime I review one of these my notes are lengthy). 
But you need to review the EOB and and just I just simply cringe. Why? What? How would you apply that denial code is clearly burning in my mind. I am here for you.


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