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United Heathcare / Denial of benefits

1 Boise, ID, United States Review updated:

I went in for an emergency appendectomy and the hospital cleared everything with UHC. 4 months later I get a bill for 6, 000.00 that they refuse to pay. They say that I did not give them notification I was going to have surgery. I didnt know either. Then the claim the hospital didnt notify them. I was right there with them when they did it upon my admission. Now they say that the hospital did not follow procedures set in place by uhc and the balance is patient responsibility. The hospital (ST. Alphonsus) will not help me with payments since I dont qualify because I have insurance. Yes but my insurance wont pay. I am to the point that I probably wont go for any type of health care without an attorney present. Who is looking out for the patient?

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  • Rc
      14th of Jul, 2010
    0 Votes

    As someone that has worked and continued to work in all areas of health insurance and billing AND have been on the same end of the stick as you, I can tell you that it has to do with the way the hospital is billing your claim. There are two key components to billing that distinguish a claim for emergent and routine services in a hospital setting. If a claim is billed as an emergent (ER visits), health insurance companies can not ask for pre-authorization or pre-certification. If a claim is billed as a routine service (w/o the emergent diagnosis included), the health insurance company can deny services, but they are typically denied as provider responsibility. In states (such as WA), it is illegal (a class C felony) for health care providers to bill subscribers for services denied as provider responsibility. If I were you, I would contact the hospital billing office and ask if they uses an emergent diagnosis (aka ICD-9 code) to bill your claim for your ER visit. If all else fail, you can utilize your state's Dept of Insurance or Dept of Insurance to assist you in resolving the issue. Typically states have consumer advocacy division of these agencies.

    Good luck and I can totally empathize with the frustration you are feeling.

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