Shady insurance practice or just a mistake?

[pb4uski]

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.

So now that you have more facts, do you think it was just a mistake or a shady insurance practice?

 

[hesperus]

Likely just a clerical error on their end. I've had this happen with a lab bill before and it was a pain to fix, but they eventually moved it to the right person. You definitely need to call and have them re-process it under your name so that deductible applies correctly.

 

[SecretlyFI]

An update that’s not much of an update:
UHC called me today and said they are still trying to figure out how to correct this in their system. It was already escalated on their end but they haven’t figured out how to fix it yet. Meanwhile, the dr’s office also contacted them and reiterated that they submitted it correctly under my name.

So, it’s a waiting game still. Not really a problem for me, since the dr’s office hasn’t billed me yet. If they do, and it’s for the full amount, I’ll just cross it out and write in my 20% coinsurance amount and pay that. And I’ll include the incorrect EOB received for DH and a recent EOB summary for me, showing I met my deductible. Then the dr’s office can fight with UHC, trying to get the rest of their payment.

 

[KarenF]

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.

Given the other extremely shady denial practices that UHC does, I vote shady. We don’t have UHC for that reason, but I am not sure that other insurance companies are much better.