Shady insurance practice or just a mistake?

[SecretlyFI]

I have been waiting for an EOB for a test I had done at end of October. I logged into United Healthcare’s site and found it under “claims”. Only problem is, it shows my DH as the patient, not me. The doctor, date and test were correct. This is a problem since I already met my deductible, but DH hasn’t. So it’s showing we owe $90 instead of $18.

This is a doctor only I have been to - DH has never been a patient there. So I know the dr’s office submitted it correctly. Which means UHC applied it to the wrong person. Can’t imagine how that’s done by accident, since I’m sure it’s automated based on policy ID and patient birthdate. So now I get to call them to get this corrected.

My question for the folks here - do you think this was a real mistake, or a shady tactic where most people wouldn’t catch it and just pay the balance. I’m sure many people don’t track their deductible progress to know what to expect on an EOB.

 

[Midpack]

Is DH the primary/first subscriber, and you joined to policy? e.g. I was on my wife's Megacorp healthcare plan as a retiree while she was still working. Just asking as it might explain how they got the wrong patient. I'd be surprised if it's a deliberate "tactic" but you'll be the first to know.

 

[SecretlyFI]

Good question. No, I’m the primary as it’s through my former employer. I retired a few months ago and did COBRA for me & DH (no plan changes, same insurance card) and my son went on his employer’s.

Previous bills from that dr earlier this year were processed correctly. I think it’s shady…I could picture an algorithm that could accomplish this.

 

[engineernerd]

Impossible to know for sure whether it was deliberate, unless a UHC whistleblower goes public.

 

[MichaelB]

Hanlon’s Razor

Never attribute to malice that which is adequately explained by stupidity.

 

[SecretlyFI]

I agree. If this is an automated process, then I think it’s on purpose. If a human applies claims, then I can see stupid mistake. I just find it hard to believe this is a human, manual process. Even before the AI revolution of late.

 

[grasshopper]

Have you been sent a bill for the deductible? Most offices won't let you leave without paying. I have been to see my GP in the morning and my chiropractor in the afternoon, and they knew I paid my deductible portion to the GP.

 

[pb4uski]

I agree. If this is an automated process, then I think it’s on purpose. If a human applies claims, then I can see stupid mistake. I just find it hard to believe this is a human, manual process. Even before the AI revolution of late.

Ah, the old conspiracy theory, eh? It's probably a mistake. Why would one immediately think otherwise without any facts? The big ol insurance company is out to get YOU!

 

[SecretlyFI]

Have you been sent a bill for the deductible? Most offices won't let you leave without paying. I have been to see my GP in the morning and my chiropractor in the afternoon, and they knew I paid my deductible portion to the GP.

I haven’t received a bill yet, but the EoB was just approved earlier this month, so it should be coming soon. Actually, I expect the bill to be delayed because when the office receives the info from UHC of the payment they made for DH, I expect the office to say “Who’s that? We don’t have a patient by that name”.

I never pay bills at an office visit. On the rare occasions that I’ve been asked to, I always tell them that I wait until I receive an EOB and invoice before I pay a bill. That’s been an acceptable response in my experience.

 

[SecretlyFI]

Ah, the old conspiracy theory, eh? It's probably a mistake. Why would one immediately think otherwise without any facts? The big ol insurance company is out to get YOU!

I already mentioned that I really don’t think that claims processing is a manual process by a human. I even googled if UHC does automated claims processing and it came back with plenty of info on how UHC uses artificial intelligence and automation extensively throughout its claims process.

If DH was also patient, I could see the office submitting it wrong in error. But they must have submitted it under my name/birthdate/SS#. So I don’t know how UHC’s automated process would apply it to DH.

I think it’s naive to think companies don’t have things occurring in their favor where they think the customer won’t catch it. They are not in business to benefit me. I’ve experienced many scenarios at mega-corps where they practice “plausible deniability” and politely say “oops, sorry” when it’s caught. In fact, I learned the phrase “plausible deniability” from the Director of Finance at my big-4 CPA firm.

Particularly in this case - the gross charge was $1,000 and the negotiated amount was only $90. Many people would see that big “discount” and happily pay the balance without a second thought.

 

[grasshopper]

I agree with not paying at the office. I am 2-3 hours from all my doc's so I bunch appointments for the same day in 2 or 3 slots. I know my deductible is $202 so my demonologist gets first in line, I pay for that days bill $105. off to the GP annual wellness no charge, chiropractor $35. Now I know the next visit anywhere will only get $62 and that's it. Simple math.

 

[TripleLindy]

Was your husband listed anywhere on your account with the provider? I spent a couple of decades on the software side of claims processing and I highly doubt that the patient was switched once it left the provider’s system. Anything is possible, but it would take some human intervention to switch the patient info from you to your husband.

And as far as that “discount” goes, that’s a misunderstanding by most. No one pays that charged amount, but they see it on the bill and think they got a huge discount by being on the insurance plan. In reality, a cash payment can often be less, especially if discussed prior to the service.

 

[TripleLindy]

demonologist

Now there’s a speciality!

 

[MarieIG]

Mistake.

I have been subject to enough of them, although I have a different carrier.

 

[TripleLindy]

One other possible explanation: maybe you gave them your husband’s insurance card by mistake. Or maybe both of you are listed on your card and the provider wrongly used your husband’s member ID. The member ID, SSN, name and DOB are the most common cross references to validate the correct patient.

 

[MRG]

I already mentioned that I really don’t think that claims processing is a manual process by a human. I even googled if UHC does automated claims processing and it came back with plenty of info on how UHC uses artificial intelligence and automation extensively throughout its claims process.

If DH was also patient, I could see the office submitting it wrong in error. But they must have submitted it under my name/birthdate/SS#. So I don’t know how UHC’s automated process would apply it to DH.

I think it’s naive to think companies don’t have things occurring in their favor where they think the customer won’t catch it. They are not in business to benefit me. I’ve experienced many scenarios at mega-corps where they practice “plausible deniability” and politely say “oops, sorry” when it’s caught. In fact, I learned the phrase “plausible deniability” from the Director of Finance at my big-4 CPA firm.

Particularly in this case - the gross charge was $1,000 and the negotiated amount was only $90. Many people would see that big “discount” and happily pay the balance without a second thought.

I remember thirty years ago working implementation of automation in insurace claims processing. Its hardly novel.

As screwed up as our healthcare and insurance processes are they're barely able to get it right when all the data are correct. To introduce a level of gaming the system is difficult to imagine.

 

[SecretlyFI]

Ok, these responses have me quite curious if or how the dr’s office could have submitted under DH’s name. He’s not a patient there. His name only appears as an emergency contact for me in their records. Beyond that, they only have my DOB & SS#. Our insurance cards are identical, with one member ID and group number. My name is shown on the card as “member” and DH as “dependent”. Maybe I’ll call the dr’s office first and see what their billing info says, before I call UHC.

I’ll report back!

 

[pb4uski]

.... I think it’s naive to think companies don’t have things occurring in their favor where they think the customer won’t catch it. They are not in business to benefit me. I’ve experienced many scenarios at mega-corps where they practice “plausible deniability” and politely say “oops, sorry” when it’s caught. In fact, I learned the phrase “plausible deniability” from the Director of Finance at my big-4 CPA firm. ...

Thank you. For confirming my conspiracy theory theory!

Another Big 4 CPA here, but I also specialized in insurance and was CAO for a life & health insurer before joining the Big 4.

I'm betting it is a mistake of some sort. If you determine it is intentional then you should report it to the insurance commissioner along with whatever proof that you have.

 

[Koolau]

Ok, these responses have me quite curious if or how the dr’s office could have submitted under DH’s name. He’s not a patient there. His name only appears as an emergency contact for me in their records. Beyond that, they only have my DOB & SS#. Our insurance cards are identical, with one member ID and group number. My name is shown on the card as “member” and DH as “dependent”. Maybe I’ll call the dr’s office first and see what their billing info says, before I call UHC.

I’ll report back!

You should thank God it's only a billing error. DW got her annual chest X-ray following her condition several years after lung surgery for cancer. She had passed the "test" several years in a row but this one came back flagged "suspicious."

So her doctor called and set up a follow up test with specialized contrast/CT scan. For two weeks we were sweating bullets.

DW arrived for the test, got the IV started and got all gowned up for the test. The tech came in and asked some questions and she left. 20 minutes later, she came back and asked some more questions. Finally she called someone from her office (we could see this happening).

Finally, she came back in the room and said "Somehow your x-ray got mixed up. We found YOUR 'real' X-ray and the Dr says it looks to be just fine."

Well, relief to be sure, but what a horrible thing to have happen. THEN a couple of weeks later, the hospital sent DW a bill for the procedure that was interrupted by the good news! Is that "adding insult to injury" or "adding injury to insult"? I don't know, but we eventually got the charges taken off.

Never got an official apology (though the technician was quite beside herself with apologies at the time).

 

[jazz4cash]

I admit I don’t understand health insurance very well. I did not think it would benefit the Dr’s office in any way if you have or have not met deductible. If Dr bills $1000 and insurance says only $500 is allowed, the Dr gets $500. If my deductible and co-pays are $125, Dr gets $125 from me and $375 from insurance. If I have already met my deductible the Dr gets $500 from insurance and $0 from me.

Edit: Are you suggesting the Dr is collecting the deductible and co-pays from patient on top of being fully paid by insurance? I could see that if patient pays at the office and/or not paying attention to EOB. Also, why do they have DHs DOB and SS# if not a patient?

 

[Sue J]

I had this happen one time. I went to the hospital for pre-op testing. I had bloodwork, an EKG, BP and filled out some paperwork. Somehow, they billed it as DH being the patient. The results showed up for me, but the billing was as if he was the patient. Very strange.

I called to correct this and they removed it from his account and the whole thing disappeared. It never got billed to me. I was fine with that. This was in 2014 so I'm sure it's gone for good.

 

[OldShooter]

In almost all cases I would write this one off to human or mechanical error, but since it is United Health I would not be as quick. This is a truly slimy company with a decades-long history of skirting the rules and evading the law.

A number of years ago I heard second hand about a programmer friend who was hired by UH to work in claims processing. The story was that part of his assignment was to randomly deny valid claims from time to time, effectively putting $$ into UH's pocket. I poo-pooed it at the time, saying that no major company would take that kind of legal and reputation risk. But UH's behavior in the intervening years has made me not so sure. Example: US healthcare executive pays back $600m in stock options case - PMC

 

[SecretlyFI]

I admit I don’t understand health insurance very well. I did not think it would benefit the Dr’s office in any way if you have or have not met deductible. If Dr bills $1000 and insurance says only $500 is allowed, the Dr gets $500. If my deductible and co-pays are $125, Dr gets $125 from me and $375 from insurance. If I have already met my deductible the Dr gets $500 from insurance and $0 from me.

Edit: Are you suggesting the Dr is collecting the deductible and co-pays from patient on top of being fully paid by insurance? I could see that if patient pays at the office and/or not paying attention to EOB. Also, why do they have DHs DOB and SS# if not a patient?

It benefits the insurance company, not the dr’s office. The doctor gets paid either way, as you said. But when a charge is applied to a deductible, the patient has to pay it, instead of the insurance company (the $125 in your example).

No, I’m not suggesting the dr is double-collecting. In fact, that’s why I don’t pay at the office, I wait for the EOB and invoice.

The dr’s office does NOT have DH’s DOB or SS, since he’s not a patient there. That’s why I’m curious how this happened, and at what point in the billing cycle. I tried calling the dr’s office today but the billing person isn’t there. Will try Monday.

 

[SecretlyFI]

Update:
I checked the UHC site again and as of Friday, 2 claims show on their site for the date of service in question, This makes sense, since I had 2 procedures done that day. The 2nd one was just processed on Friday. The 2nd one shows correctly under my name. The other one still shows under DH's name.

Today I called the provider's office billing department. They show both claims as having been submitted in my name/DOB, etc. So they said I should call UHC to get it corrected. I called UHC and they show 1 claim submitted under my name and the other under DH's name. They said they need the provider to submit a "corrected claim" to get it re-processed under my name. She put me on hold while she called the provider's office to request the re-submission. 25 minutes later, she came back on the line with me and said the provider's office checked everything and they only show it under my name/DOB, etc. and they will not submit a corrected claim because there is nothing to correct on their end.

So the UHC person said she will escalate on her end to see how to get it corrected and will call me back in a couple days.

So basically, they are both pointing fingers at each other. Still seems very difficult for me to believe the dr's office submitted under DH's name since again, they don't have his DOB or SS# and only have his name as a emergency contact for me. In addition, the other claim for the same day was submitted in my name.

 

[pacergal]

Question--does the first claim show DH name but your DOB and SS? That would be the thing I would ask UH rep.
Glad the rep was willing to move it up the next chain rather than "there's nothing I can do, you need to fix it" attitude