Wiki Out of network billing!!

[Corelifebilling]

Hello!

Our practice just became in network with UHC as of June. Our effective date was 6/22/18, there was miscommunication with the rep from UHC and the person in our company who signed the contract. The person was under the impression that once the contract was signed and submitted back to the UHC rep, we were in network and able to see patients. We ended up finding out that the effective date was never discussed and we shouldn't have been seeing UHC patients until 6/22... is there a way to appeal the claims from prior to 6/22/18? Do we have to set it to patient responsibility since we were technically still out of network?
Any advise helps!! A UHC rep told us to just resub the claims after the effective date but we still havent received anything back for the dates prior to 6/22.. not even denials.

 

[MrLittlefoot]

It depends on if your contract retroactively applied to a specific date(say 6/1/18) but they couldn't get it set up until 6/22/18 or if 6/22/18 is the first day UHC considered your office contracted. I doubt that UHC will budge if you really aren't contracted until 6/22/18, so technically anything over their maximum allowable is going to be considered patient responsibility, and yes, you could charge that amount to your patients. If there was miscommunication you could also try to go above your reps head to their manager. Since you though that they were contracted and agreed to take UHC's rates anyways and the patients(I assume) thought that you were in network with UHC as well, it might be smart to write those amounts off, but if you really weren't in network, there is nothing that could make you write off those amounts.

 

[karlene.dittrich]

Utilize your rights of appeal

Hello!

Our practice just became in network with UHC as of June. Our effective date was 6/22/18, there was miscommunication with the rep from UHC and the person in our company who signed the contract. The person was under the impression that once the contract was signed and submitted back to the UHC rep, we were in network and able to see patients. We ended up finding out that the effective date was never discussed and we shouldn't have been seeing UHC patients until 6/22... is there a way to appeal the claims from prior to 6/22/18? Do we have to set it to patient responsibility since we were technically still out of network?
Any advise helps!! A UHC rep told us to just resub the claims after the effective date but we still havent received anything back for the dates prior to 6/22.. not even denials.

You have the right of appeal which you should always exercise in any situation where claims are not paid appropriately, including out of network. For supporting data, go to FairHealthConsumer.org and enter your CPT codes (Keep in mind that entry limits apply per week) and zip code to find out what the appropriate UCR is for your area. Use this information to challenge any underpayments made by UHC in an appeal process. Relevant laws support that as it pertains to Out of network billing, Billed - Deductible - Co-insurance should= payment, anything less than that should be challenged.

 

[KN]

Appeal all Claims

You should try to appeal all claims that were denied, utilizing the information from the contract representative. Appeals should be made on the foundation that UHC did not act in good faith to provide an exact date in which the provider became PAR. Due to this misinformation/miscommunication UHC members would now have the burden to pay for services in which they did not expect. Your physician(s) provided services in good faith based upon the expectation of payment from UHC and now UHC has seriously jeopardized your ability to collect monies from members due to this error/misinformation. Urge them to reimburse your provider as moving forward you wish to have relationship with UHC and that your facility followed all the rules/protocols of UHC for these claims. I would consider having your provider draft a letter reflecting the issue and submit with the appeal. I would also send member appeals and ensure you use a Designated representative form, legally assigning your provider to submit an appeal on the member's behalf. UHC makes far too many errors in claim processing and showing them you do not write off claims shows your office is effective in fighting for your and your patients rights.

 

[TMoore1205]

Hey there,

Yes you can try to appeal, but the best thing to do is to work with your Network Manager to have the claims or contract retroactive to the date you begin billing. This is exclusively up to UHC. Because there was a misunderstanding they should be willing to work with you, unfortunately you can't hold the patients responsible for these unpaid claims if you didn't inform the patient that they were being seen out of network.

Billing Manager
Torrancia Moore