I just received this letter in the mail:
Informational copy only. Original letter addressed to MSPT (my office)
Dear Billing Department:
We're responding to your 011708 inquiry about our processing Susie on 12/26/07.
We determined that we processed this claim accurately and no further payment is due. The reason (s) is listed at the bottom of this letter.
Network physicians/ other health care professionals/ facilities: Please refer to your administrative guide for further review options.
Non network physicians: Please refer to the PRA for any review rights that may be available to you.
If you have questions about this letter please call customer care.
Under the plan, notification was required but not received. Therefore, we have declined payment for the service because requirements of the plan were not met.
Let me explain the absurdity of this. First of all, I have been in PT for 10 months now (and counting). My plan only allows for 30 PT visits/ year, in or out of network. My office is in network, but my therapist is out of network (it is a big game we play with the insurance companies). To access my in-network benefits, authorization is needed by an outsourced PT company who will read P's notes and 'approve' x number of visits. Then he requests more, and it becomes a pile up of paperwork and a losing battle with the insurance company. I have out of network benefits too. These do not require authorization (i.e prior notification), and get billed at a higher rate and paid at a higher rate. So the billing department has been billing out of network. It is great for everyone. I get my deductible taken care of (they obviously don't charge me), P has no paperwork, and the office gets paid more. These out of network visits are also capped at 30, but no one seemed to notice, or someone in the billing department appealed them...who knows. All I know is that PT has been paid for, very well I might add, for the last 10 months. And I have definitely exceeded 30 visits (I think I exceeded 30 visits with one surgery alone! Dr.Kelly's PT protocol is for 1x/week x 1st month, 2x/week 2nd month, 3x/week 3rd month) At some point in time, it became more difficult to bill out of network so the billing people started billing in network. They have done so for a while, and now, United Healthcare realized there was no authorization. Oops!
I keep forgetting to count the total # of visits I have had, it is scary though! I have an appintment tomorrow that I am keeping!
I am finally feeling less tight in the capsule. Ironically, I have not been on my bike since Thursday bc of all the family outings. Tonight I am finally in bed, alone, and ready to sleep ALOT!
4 comments:
Susie - OMG! I got the exact same letter from the good folks at United Healthcare. But mine is regarding my actual surgery, not the PT. The annoying thing about it is 1) my OS is in network, and 2) I was told that I didn't need to get an authorization from my PCP. I asked 3 different people about that, and I got the same answer from all three of them. My hip scope was in early December '07, and I have yet to receive any bills from anyone. I keep getting stuff that indicates "This is not a bill", and it looks like serious disputes are going on between the OS's practice and UHC as well as the hospital and UHC. I've also been checking the myUHC site for my account, and it is like trying to figure out the mystery of the pyramids. I'm just waiting for the day when I get some big, huge bill
from the OS and/or the hospital, that has already gone to a collection agency, because I haven't paid my bills.
BTW, I'm luckier than you in my plan -- I'm allowed 40 PT visits per year, but once a month, I have to fill out several pages for United Healthcare that has ratings for how well I can do certain things. The PT tallies them up and sends them in. She says that as long as progress is being shown, but it still shows that I'm struggling enough, I will be able to get the insurance to pay for my PT. But I'm sure that some day, the number will go over some mysterious limit that has been set for "lower extremity ratings" and I will get a letter saying that I can no longer get PT. That is the day that I will start paying out of pocket, because I'm sure that day will be sooner than I want to give up on getting very beneficial PT.
This stuff would make a great reality TV show, because it is so absurd!
Good luck with your recovery!
We decided to go out of network to avoid the nasty paperwork, and it worked. They overlooked the 30 visits/ year, and even when things got denied, they were somehow resubmitted and paid for. I'd rather stay in the dark than ask too many questions!
You probably haven't been billed bc they are disputing it (OS office) and resubmitting it. I had that with my CPM and gameready, which ultimately was denied, I am now in a "second level appeal" with UHC regarding it. Hopefully it will get paid though!
Good Luck getting your surgery paid for!
Susie,
So ultimately did UHC pay for the FAI arthroscopy? Many of the other insurance companies seem to think it's investigational. I'm a little anxious as I had my 2nd scope a few weeks ago and ended up with a femoral neck debridement and the diagnosis was FAI. I'm worried that UHC determines that the scope for FAI is in fact investigational. Thanks.
Maria-
They did pay for all surgeries with FAI work. Do a search on my blog for "cost of hip arthroscopy" and you will see what was paid out for each surgery.
Post a Comment