About 4 million people in Florida are insured by UnitedHealthcare, a company facing backlash after its CEO was shot to death in Manhattan, followed by public outrage over its pattern of coverage denials.
Florida represents UnitedHealthcare’s second largest market after Texas, providing coverage through employee plans, the Affordable Care Act open marketplace, and Medicare Advantage plans.
UnitedHealthcare’s Coverage Denials
This week, the insurer’s prior authorization and coverage denials in the state drew the same anger and frustration seen nationwide on social media in the wake of the shooting. Florida lawyers, insurance advocates, and medical billing experts say being informed about UnitedHealthcare’s practices, making smart choices, and fighting back is critical, especially now that the insurer uses sophisticated artificial intelligence (AI) to deny approvals and claims. According to consumer research site, ValuePengiun, UnitedHealthcare denies claims at a rate nearly double the industry average and now faces a barrage of lawsuits, including hundreds in Florida.
“People are paying lots and lots of money for this insurance and then they get screwed over by the company,” said Doug Wolfe, a healthcare attorney and managing partner of Wolfe Pincavage in Miami. “They’re giving all this money to them, and when they need it the most, they deny the claim.”
Seniors’ Concerns
Of UnitedHealthcare’s Florida members, over 1.2 million seniors hold Medicare Advantage plans. Experts say seniors need to be particularly aware of their rights as they become increasingly more likely to have their claims denied, pay more for premiums and medical visits, and face unexpected costs for care they thought was covered by their health plan.
An October Senate report shows one of the biggest complaints against UnitedHealthcare is that it denies senior Medicare Advantage plan holders approval for rehabilitation or nursing care after hospital stays at far higher rates than other types of care. The report found that UnitedHealthcare authorized home health services instead, which cost the insurer less and require a heftier patient responsibility.
Appealing Coverage Denials
As an individual, navigating the pre-authorization and payment denial process requires stamina, attention to detail, and often legal representation. Experts say it is usually worth the effort, especially when receiving needed medical care or the reality of medical debt hangs in the balance.
A KFF analysis of privately managed Medicare Advantage plans discovered only about 10% of patients appeal insurance denials, and about one-third of those appeals fail.
“How to Make an Appeal”
* Dig through the insurer’s denial letter to find instructions for the appeal process.
* Document every step of the process, advises Russel Lazega, a Dania Beach insurance claims lawyer.
* Gather a direct response to their denial from your doctor and add your additional medical records to it.
External and Federal Appeals
If unsuccessful, the next step is an external appeal to a company hired by the insurer. “It’s important to have your documentation in the file. Any documentation pertaining to your appeal won’t be looked at unless it’s already in the file. Adding it later is hard, so don’t give the insurance company that technical advantage,” Lazega said.
The final step is federal court. Lazega said people in life-or-death medical situations tend to go this route. The patient pays legal fees, not the insurance company.
UnitedHealthcare’s Response
UnitedHealthcare approved and paid about 90% of medical claims upon submission. Importantly, of those that require further review, around one-half of one percent are due to medical or clinical reasons. Highly inaccurate and grossly misleading information has been circulated about our company’s treatment of insurance claims.
“We do not use AI to make adverse coverage determinations. Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan.”
Hospitals and Doctors Fighting Back
Hospitals are fighting back against insurer rejections, too. Most have their own artificial intelligence to scan denials for mistakes. They hire companies like Health Business Solutions in Davie to appeal fees that UnitedHealthcare refuses to pay when it deems a procedure or treatment unnecessary.
Doctors say they are fighting denials, too. Dr. Georgiy Brusovanik, a Miami spine surgeon, says he tries to help patients obtain coverage, but also finds himself fighting for his fees from the insurers. “The problem is they just don’t pay me,” he said of UnitedHealthcare. “They usually get you on a technicality.”
Conclusion
UnitedHealthcare’s pattern of coverage denials has sparked outrage and frustration among its Florida members. As the insurer continues to face backlash, it is crucial for individuals to be informed about its practices and to take action to fight back against denials. By understanding the appeal process and documenting every step of the way, individuals can increase their chances of successfully appealing coverage denials.
FAQs
Q: What is the average rate of coverage denials for UnitedHealthcare?
A: According to ValuePengiun, UnitedHealthcare denies claims at a rate nearly double the industry average.
Q: How many seniors hold Medicare Advantage plans with UnitedHealthcare in Florida?
A: Over 1.2 million seniors hold Medicare Advantage plans with UnitedHealthcare in Florida.
Q: What is the most common complaint against UnitedHealthcare among seniors?
A: The most common complaint is that UnitedHealthcare denies approval for rehabilitation or nursing care after hospital stays at far higher rates than other types of care.
Q: How many patients appeal insurance denials?
A: Only about 10% of patients appeal insurance denials, and about one-third of those appeals fail.
Q: What is the final step in the appeal process?
A: The final step is federal court, where patients can seek legal representation to fight for their coverage.
