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Having served on the medical insurance board at work ;I agree with emilybl. Even with the same comapny and within the same type of coverage ;the plans can be quite different. You want more ;it cost more is the basics.If in a PPO or HMO you also need to be aware that the hospital maybe within the network but they may use outside providers that are not and your plan may not pay. So it is best to check what hospitals within the plan also use providers for pathology etc within the plan.Otherwise you pay big time for the difference between what is bill and what the insurance will pay even if they agree to pay the in network amount.
I work in healthcare. My Golden Rule plan was a PPO. What I was trying to say was that the same provider could be in network with United (who owns Golden Rule) but is not in network with Golden Rule. If you try to access the provider list from the Golden Rule website, it will take you to the United list, and that is not always accurate. Providers who submit claims under Golden Rule have systems that direct electronic claims to be filed to the United processing site and will reject. I just had breast cancer and had to go through the nightmare of trying to untangle where claims are being filed. Just because providers make a photocopy of your ID card does not mean it would go to the correct processing center. My advice is for anyone that will use a United or subsidiary company, call the customer number yourself and verify the address and/or control numbers to be used to file your claim, including fax and phone numbers. Insurance companies use different control numbers when providers electronically submit the claims or when they submit paper ones. The provider systems are not always equipped to handle the difference and it is up to you to assist that process or it would end up being your headache later.
Additionally, when your treatments involve facilities and physicians, make sure that both of them are in network. Just because one is does not mean all are. For example, radiology treatments are 3-part - you have the physical facility, you have the technicians and you have the professional component, the radiologist who reads the results. They may or may not belong to the same practice and they may or may not be ALL in-network. Understand your coverage, maintain a spreadsheet so you know how your claims accumulate toward satisfaction of your deductible, read your EOB and question the procedures you had done. Make sure that the original billed charges are being adjusted to account for your provider being part of the network.
Last edited by BagongBuhay; 04-05-2008 at 06:55 AM..
Reason: addition
Having served on the medical insurance board at work ;I agree with emilybl. Even with the same company and within the same type of coverage ;the plans can be quite different. You want more ;it cost more is the basics.If in a PPO or HMO you also need to be aware that the hospital maybe within the network but they may use outside providers that are not and your plan may not pay. So it is best to check what hospitals within the plan also use providers for pathology etc within the plan.Otherwise you pay big time for the difference between what is bill and what the insurance will pay even if they agree to pay the in network amount.
All you need to do is: before you enroll in a specific plan, specify to the agent that you want a PPO plan and then look at the list of providers and/or call your doctor's office and ask if they are a "participating provider" of United Healthcare or of Beacon or of Private Health Care Systems or whatever the name of the PPO network is. Make sure you use those precise words and DO NOT SAY, "do you take" or "do you accept" because most doctors will say yes even though they are not a member of the PPO and then they will bill the carrier and the carrier will remunerate them based on "reasonable and customary" rates for the area; you'll get an explnation of benefits statement showing what ws billed and what the insurer paid and then the doctor often will balance bill you for the difference. If your doctor is a participating provider, the statement will show the initial bill and then show the discounted rate paid to the doctor (which the doctor in the PPO must accept as payment in full.)
All I know is if you are seeing a specialist before you enroll in United and that specialist isn't a provider for United, you are scre.wed. United makes it very hard for therapists to join and from what I heard their reimbursement rates are laughable. Now, I know the client shouldn't care what the provider gets paid for, but in some cases the client wants to continue to see their therapist but can't.
The company I work for changed insurance companies. I filled out paper
work in Dec 06 and was told we would receive cards in mail. Jan 9, 2007
(Sunday)my husband awoke with chest pains. I took him to the hospital. His heart
beat was 185 The doctor had to shock him 4 times to regulate his heart
beat and performed a dye test for blockage. I had not yet received the
insurance cards and told the hospital this, they told me when I got back
to work and could get the information to let them know. I called my HR
person and she gave me some information to go on line and get the
information I needed. The insurance company refuses to pay the bill
because the hospital did not inform the of the procedures before the
performed them. Help! I don't know what to do! How can they refuse to pay when I did not have a card?
I have had United Health Care on some of my employer-sponsored health plans at work, and had no problem with them. In fact, I consider them the best insurance I've had. Wish I had them now, in fact.
The company I work for changed insurance companies. I filled out paper
work in Dec 06 and was told we would receive cards in mail. Jan 9, 2007
(Sunday)my husband awoke with chest pains. I took him to the hospital. His heart
beat was 185 The doctor had to shock him 4 times to regulate his heart
beat and performed a dye test for blockage. I had not yet received the
insurance cards and told the hospital this, they told me when I got back
to work and could get the information to let them know. I called my HR
person and she gave me some information to go on line and get the
information I needed. The insurance company refuses to pay the bill
because the hospital did not inform the of the procedures before the
performed them. Help! I don't know what to do! How can they refuse to pay when I did not have a card?
They are not denying payment because you don't have the card. You yourself said that they were denying it because one of the procedures the hospital performed required precertification. This was the hospital's responsibility to call the insurance company even without the card. The insurer would have a record of your coverage through your SSN. I would discuss this with the hospital, unless they felt that the procedure was performed as part of the emergency treatment.
Location: Sometimes Maryland, sometimes NoVA. Depends on the day of the week
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I have United Healthcare and I can't wait to switch in November. I was 100% happy with my PPO plan, until they were bought out by United Healthcare. Granted, I'm not nearly as sick as I was then, and require a lot fewer doctor's visits, but I totally hate that they will deny things based on their opinions rather than your doctor's. Speaking of precertification, I had a CT scan scheduled last year. Same one I've gotten 4 times a year for the past 4 years. Required precertification for the neck but not the chest. (and even that was new with United, before being bought out, my PPO didn't require precert for either). Well, we got the precert for the neck, they then denied the chest b/c we didn't get precert. After we were told the chest did not require precert. So frustrating. On the plus note, I just let the doctor's office and insurance company fight it out and have not seen a bill.
That said, I have serious issues with a company that is in the health business, that is *my* health, being a for-profit company that pays their CEO $1.25 million a year. This has far more to do with why I am switching that their precert policies.
I used to have United PPO, it was a good plan and I never had a problem getting my claims paid but then again it was only normal stuff, no hospitilizations.
I had more problems with BC BS, in my area here in Florida they are known for not paying their claims and the provider having to do all kinds of appeals and such.
When I worked for a durable medical equipment company I found out that when providers call to get benefits from United, they are routed to a call center in India. I was not thrilled about that. These people have access to alot of personal information but are not bound by American regulations on privacy.
Our much loved pediatrician informed us that she would be dropping UHC POC at the end of the year. The insurance company has not raised the rates they pay the Doctor in 5 years. UHC has raised what they have charged us every single year. This year our corporation is getting hit with an average increase of 18% for health care. United Healthcare has made me disgusted with this business plan. I would recommend the OT not even begin the battle with the company. It will be a lot of lost hours for no financial benefit.
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united heath care insurance refuses to pay
The doctor had to shock him 4 times to regulate his heart
UHC POS - bad for doctors
