Wiki Has anyone else experienced this with Optum/UHC?

[ncm1980]

I currently work in the capacity of a reimbursement specialist for an independent laboratory and there is a sudden increase in incorrect denials from UHC/Optum.
We are a contracted provider and submit the Test Request Form (TRF) and results for pre-payment review. As time consuming as that is, it’s pale in comparison to having to submit individual reconsiderations for each incorrect claim denial for the same reason (this began less than 2 months ago). I’ve gone back and forth with both Optum and UHC and submitted a “Claim Research Project” to UHC (per Optum’s suggestion). Days later, I get an email from someone UHC staring that “these” issues are not handled by the “CPM Department”.
I’m making our payor market group involved, but I didn’t know if anyone else has had a similar experience and been able to resolve it. I’m at a loss as it feels like Optum and/or UHC is looking for any reason to delay adjudication of payable claims in hopes they fall through the cracks.

 

[cschoocpc]

I own a billing/coding company and have similar issues. They request medical records on almost ALL of the anesthesia claims we submit. Even for screening colonoscopies! Then, after uploading the medical records, via their portal, they will often deny as a duplicate or other erroneous reasons. We then do a claim reconsideration via their portal and it often gets denied again. We get to the point where we have to file an appeal for a screening colonoscopy (claim is clean- surgeon has listed a screening diagnosis code and we use the correct screening CPT codes and modifiers). But, they deny the appeal as we don’t have a signed authorization from the patient to appeal on their behalf.

I believe they are just doing this in hopes that providers just give up and/or don’t respond to their denials in a timely fashion so they can deny for yet another reason!
I’ve had to hire an employee whose job is almost 100% spent on UHC/Optum issues for this ONE anesthesia provider—and provider is in-network!!

Getting a provider rep involved is useless!

I believe they are doing this to many providers. I am waiting for a class action suit to be filed for their dubious practices. Contacting state dept of insurance is not helpful either.

I’ve been in this field for over 20 years and have never encountered such a racket.

 

[ncm1980]

UGH… but thank you for the response.
I had 2 other major payors I was working that had to be reassigned b/c of the volume of denial letters from Optum.
I was a coder for years but also became a denial SME because it just makes sense to me. After a 9 career pause for my family, I figured things had to be better now than they were back then. UHC has gotten worse, and I didn’t think that was possible.