Dear Revdex.com,We have received an appeal from [redacted] concerning this matter as well***'s claims for the University of Utah Healthcare Non-invasive Vascular Lab were processed according to ***'s benefit planWe follow the guidelines for the Affordable Care Act Preventable care benefits for adultsPreventive Services are determined by the way a claim is billed, there are certain diagnosis and procedure codes that indicate if a procedure is considered PreventiveThis claim was not billed to us as a preventive service, so we did not reimburse the claim under ***'s Preventive Services benefitWe are in the process of reviewing [redacted] ***'s appeal to see if this service should be considered a preventive serviceMr***'s complaint states that we are unwilling to work with the billing office, but unfortunately we are unable to tell a Provider which codes to billThe provider and their coders are the only ones who can decide which code is appropriate for the services that are provided to a patientThe member called our office again on 2/8/18, according to the notes from the call our Customer Service Representative spoke with the billing office and the billing office is reviewing the claims to see if there are more appropriate codes that should have been billed for this date of serviceOur notes state they spoke with a woman named Lia and she will contact the member within days to let him know if there is another way that they can bill the claimsIt is also noted that Lia mentioned that the U Billing department might be able to write off the amount the patient owes for this serviceThey will contact the member with the resolutionPlease let us know if you have any other questions regarding this situation or if there is anything else that we can help withThank you,Jill J [redacted] Managed Care Coordinator, University of Utah Health Plansjillian.j [redacted] @hsc.utah.edu
Complaint: ***
I am rejecting this response because:The University Hospital has not waived the charges for the procedure. Even if they did, it does not relieve the University of Utah Health Plans (UUHP) of its responsibility to research and fairly settle the claimI think I am caught in the middle of two bureaucracies that use different coding schemes for preventive care and between two bureaucracies that are unwilling to work together to troubleshoot and find a fair solution to the coding dispute.According to the Hospital Billing representative, the Hospital coded the bill as a Z Code that she said is preventative care. The Hospital has tried to recode and resubmit the bill several times but UUHP continues to deny the claims as not being preventive care. UUHP said they go by a CPT codeDuring my call to UUHP on February 8, 2018, the UUHP representative did a search of the procedure and found five CPT codes that are preventive codes for the procedure but refused to provide those codes to the Hospital representative. The UUHP representative also did an internet search and saw that the procedure is a preventive care procedure for a patient with my demographics and medical history. The Hospital representative pointed out to the UUHP representative that without providing guidance on acceptable coding, UUHP is expecting the Hospital to code the bill blindlyThe Hospital representative also said the Hospital could not change the CPT code.I think UUHP needs to review their coding procedures and claim review procedures to make sure their coding is correct and that there are not flaws in their procedures. I also think we need an independent review of UUHPs claim settlement procedures by a regulatory agency to make sure they have not violated fair claim settlement practices and have the proper coding review. I would appreciate UUHP providing the name of the appropriate regulatory agencies that I can request a review and investigation. I believe that by law they have to provide that information and information on how to file a complaint with the regulatory agency.Regardless of the coding, I have provided UUHP evidence that the procedure was preventative. In fact, the procedure was recommended to me in MyChart, which is the communication vehicle for UUHP. So in effect, UUHP is denying a claim for preventive care that they recommended to me as preventive care. Utah State RUnfair Accident and Health Claims Settlement Practices requires “conducting a reasonable and complete investigation” before denying an insurance claim. It is certainly an unfair practice to expect the patient to dictate or resolve a bill-coding dispute between two medical bureaucracies. This claim could be resolved quickly if UUHP would research the medical literature on the medical procedure that was performed and/or talk to the doctor who prescribed the procedure. The medical literature and the doctor will confirm that this procedure was preventive careHere is a summary of the situation:1. The doctor who ordered the procedure says the procedure is preventive care.2. The Hospital agrees that the procedure is preventive care and has tried recoding and resubmitting the bill several times as preventive care.3. The medical literature on the procedure says it is preventive care.4. MyChart recommended the procedure as preventive care.5. UUHP has identified other codes for this procedure that they accept as preventive care but will not provide those codes to the Hospital.6. UUHP rejects the claim because they say it is not coded as preventive care but will not help troubleshoot or help solve the problem.Again, I asking for UUHP to help troubleshoot this claim and find a workable solution. Otherwise, I am not sure how to break this stalemate without an independent review or legal action. I also think this experience should be a forewarning to others about the type of customer service provided by UUHP and about the way they settle claims. UUHP is the worst insurance claims settlement organization that I have dealt with during my work career. Other organizations have assisted in working through issues and helped find win-win solutionsThis is the first year my employer has used UUHP. I hope my employer drops UUHP and goes back to the claims settlement organization that they used last year or finds an organization that is more willing to cooperate in investigating, problem solving, and fairly settling claims.I have another concern with UUHP’s response. They have used my name in the response. I want to make sure that my name and any other personally identifiable information is removed from their response if the Revdex.com posts this exchange online
Sincerely,
*** ***
Dear Revdex.com,We have received an appeal from [redacted] concerning this matter as well. [redacted]'s claims...
for the University of Utah Healthcare Non-invasive Vascular Lab were processed according to [redacted]'s benefit plan. We follow the guidelines for the Affordable Care Act Preventable care benefits for adults. Preventive Services are determined by the way a claim is billed, there are certain diagnosis and procedure codes that indicate if a procedure is considered Preventive. This claim was not billed to us as a preventive service, so we did not reimburse the claim under [redacted]'s Preventive Services benefit. We are in the process of reviewing [redacted]'s appeal to see if this service should be considered a preventive service. Mr. [redacted]'s complaint states that we are unwilling to work with the billing office, but unfortunately we are unable to tell a Provider which codes to bill. The provider and their coders are the only ones who can decide which code is appropriate for the services that are provided to a patient. The member called our office again on 2/8/18, according to the notes from the call our Customer Service Representative spoke with the billing office and the billing office is reviewing the claims to see if there are more appropriate codes that should have been billed for this date of service. Our notes state they spoke with a woman named Lia and she will contact the member within 5 days to let him know if there is another way that they can bill the claims. It is also noted that Lia mentioned that the U Billing department might be able to write off the amount the patient owes for this service. They will contact the member with the resolution. Please let us know if you have any other questions regarding this situation or if there is anything else that we can help with. Thank you,Jill J[redacted]Managed Care Coordinator, University of Utah Health Plansjillian.j[redacted]@hsc.utah.edu
The consumer is correct in that the claim was not billed correctly, which has been corrected and a new claim was submitted today. We apologize for the inconvenience.
Dear Revdex.com,We have received an appeal from [redacted] concerning this matter as well***'s claims for the University of Utah Healthcare Non-invasive Vascular Lab were processed according to ***'s benefit planWe follow the guidelines for the Affordable Care Act Preventable care benefits for adultsPreventive Services are determined by the way a claim is billed, there are certain diagnosis and procedure codes that indicate if a procedure is considered PreventiveThis claim was not billed to us as a preventive service, so we did not reimburse the claim under ***'s Preventive Services benefitWe are in the process of reviewing [redacted] ***'s appeal to see if this service should be considered a preventive serviceMr***'s complaint states that we are unwilling to work with the billing office, but unfortunately we are unable to tell a Provider which codes to billThe provider and their coders are the only ones who can decide which code is appropriate for the services that are provided to a patientThe member called our office again on 2/8/18, according to the notes from the call our Customer Service Representative spoke with the billing office and the billing office is reviewing the claims to see if there are more appropriate codes that should have been billed for this date of serviceOur notes state they spoke with a woman named Lia and she will contact the member within days to let him know if there is another way that they can bill the claimsIt is also noted that Lia mentioned that the U Billing department might be able to write off the amount the patient owes for this serviceThey will contact the member with the resolutionPlease let us know if you have any other questions regarding this situation or if there is anything else that we can help withThank you,Jill J [redacted] Managed Care Coordinator, University of Utah Health Plansjillian.j [redacted] @hsc.utah.edu
Complaint: ***
I am rejecting this response because:The University Hospital has not waived the charges for the procedure. Even if they did, it does not relieve the University of Utah Health Plans (UUHP) of its responsibility to research and fairly settle the claimI think I am caught in the middle of two bureaucracies that use different coding schemes for preventive care and between two bureaucracies that are unwilling to work together to troubleshoot and find a fair solution to the coding dispute.According to the Hospital Billing representative, the Hospital coded the bill as a Z Code that she said is preventative care. The Hospital has tried to recode and resubmit the bill several times but UUHP continues to deny the claims as not being preventive care. UUHP said they go by a CPT codeDuring my call to UUHP on February 8, 2018, the UUHP representative did a search of the procedure and found five CPT codes that are preventive codes for the procedure but refused to provide those codes to the Hospital representative. The UUHP representative also did an internet search and saw that the procedure is a preventive care procedure for a patient with my demographics and medical history. The Hospital representative pointed out to the UUHP representative that without providing guidance on acceptable coding, UUHP is expecting the Hospital to code the bill blindlyThe Hospital representative also said the Hospital could not change the CPT code.I think UUHP needs to review their coding procedures and claim review procedures to make sure their coding is correct and that there are not flaws in their procedures. I also think we need an independent review of UUHPs claim settlement procedures by a regulatory agency to make sure they have not violated fair claim settlement practices and have the proper coding review. I would appreciate UUHP providing the name of the appropriate regulatory agencies that I can request a review and investigation. I believe that by law they have to provide that information and information on how to file a complaint with the regulatory agency.Regardless of the coding, I have provided UUHP evidence that the procedure was preventative. In fact, the procedure was recommended to me in MyChart, which is the communication vehicle for UUHP. So in effect, UUHP is denying a claim for preventive care that they recommended to me as preventive care. Utah State RUnfair Accident and Health Claims Settlement Practices requires “conducting a reasonable and complete investigation” before denying an insurance claim. It is certainly an unfair practice to expect the patient to dictate or resolve a bill-coding dispute between two medical bureaucracies. This claim could be resolved quickly if UUHP would research the medical literature on the medical procedure that was performed and/or talk to the doctor who prescribed the procedure. The medical literature and the doctor will confirm that this procedure was preventive careHere is a summary of the situation:1. The doctor who ordered the procedure says the procedure is preventive care.2. The Hospital agrees that the procedure is preventive care and has tried recoding and resubmitting the bill several times as preventive care.3. The medical literature on the procedure says it is preventive care.4. MyChart recommended the procedure as preventive care.5. UUHP has identified other codes for this procedure that they accept as preventive care but will not provide those codes to the Hospital.6. UUHP rejects the claim because they say it is not coded as preventive care but will not help troubleshoot or help solve the problem.Again, I asking for UUHP to help troubleshoot this claim and find a workable solution. Otherwise, I am not sure how to break this stalemate without an independent review or legal action. I also think this experience should be a forewarning to others about the type of customer service provided by UUHP and about the way they settle claims. UUHP is the worst insurance claims settlement organization that I have dealt with during my work career. Other organizations have assisted in working through issues and helped find win-win solutionsThis is the first year my employer has used UUHP. I hope my employer drops UUHP and goes back to the claims settlement organization that they used last year or finds an organization that is more willing to cooperate in investigating, problem solving, and fairly settling claims.I have another concern with UUHP’s response. They have used my name in the response. I want to make sure that my name and any other personally identifiable information is removed from their response if the Revdex.com posts this exchange online
Sincerely,
*** ***
Dear Revdex.com,We have received an appeal from [redacted] concerning this matter as well. [redacted]'s claims...
for the University of Utah Healthcare Non-invasive Vascular Lab were processed according to [redacted]'s benefit plan. We follow the guidelines for the Affordable Care Act Preventable care benefits for adults. Preventive Services are determined by the way a claim is billed, there are certain diagnosis and procedure codes that indicate if a procedure is considered Preventive. This claim was not billed to us as a preventive service, so we did not reimburse the claim under [redacted]'s Preventive Services benefit. We are in the process of reviewing [redacted]'s appeal to see if this service should be considered a preventive service. Mr. [redacted]'s complaint states that we are unwilling to work with the billing office, but unfortunately we are unable to tell a Provider which codes to bill. The provider and their coders are the only ones who can decide which code is appropriate for the services that are provided to a patient. The member called our office again on 2/8/18, according to the notes from the call our Customer Service Representative spoke with the billing office and the billing office is reviewing the claims to see if there are more appropriate codes that should have been billed for this date of service. Our notes state they spoke with a woman named Lia and she will contact the member within 5 days to let him know if there is another way that they can bill the claims. It is also noted that Lia mentioned that the U Billing department might be able to write off the amount the patient owes for this service. They will contact the member with the resolution. Please let us know if you have any other questions regarding this situation or if there is anything else that we can help with. Thank you,Jill J[redacted]Managed Care Coordinator, University of Utah Health Plansjillian.j[redacted]@hsc.utah.edu
The consumer is correct in that the claim was not billed correctly, which has been corrected and a new claim was submitted today. We apologize for the inconvenience.