HEALTH PLANS: Hey, wasn’t UHC supposed be nice now?

Having been the first health plan to say that it was going to stop hassling physicians back in 1999, I thought United was supposed to be behaving itself and promoting love, flowers and puppy-dogs all around with its providers. (Well apart from that quality ranking stuff in St Louis). Well apparently the answer is not exactly not exactly:

The Arizona Department of Insurance on Friday ordered United Healthcare to pay civil penalties totaling $364,750 — the largest fine in the department’s history — for violations of state insurance laws. State regulators said United Healthcare illegally denied more than 63,000 claims by doctors without receiving all of the information needed to accept or deny a claim. The company also failed to follow state laws for promptly notifying doctors and patients about about decisions and appeals, the state said. United also violated a 2002 agreement to correct previous violations, the state said.
Just a word of warning to the payers that the providers are ready to step it up, just in case you’ve got any ideas — like say insisting on proper documentation, or rewarding for quality (and punishing for the lack of it). And that if you’re going to throw stones, better make sure that you don’t live in a glasshouse yourself.

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  1. can anyone help-uhc without my knowledge has started to deny claims on my wifes healthcare saying because she is ELIGIBLE for medicare, they will only pay as a secondary provider. My wife was covered by uhc for 2 years prior to my retirement from ups and 4 years since. They have even gone back and back billed the providers they had paid last year. An appeal was filed, over a month ago, still no response. On the monthly statements they are showing that medicare is paying the bill and they are paying as a secondary provider and she does not and has not had that coverage since 2005 when it was cancelled.

    Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
    The U.S. District Court for the District of New Jersey dismissed May 13 a qui tam action alleging violations of the False Claims Act (FCA) by United Health Group and its subsidiaries. According to the court, the complaint failed to state a claim upon which relief could be granted under the FCA. Relator Charles Wilkins began employment with United Health Group and its subsidiary AmeriChoice in October 2007 as a sales representative. Relator Darryl Willis began employment with United Health Group and AmeriChoice in 2007 as the general manager for Medicare/Medicaid marketing and sales.
    In their qui tam complaint, relators allege 11 violations of Medicare and Medicaid regulations. The United States declined to intervene in the case and the relators filed an amended complaint that stated one federal count—violation of 31 U.S.C. § 3729(a)(1)-(3)—and nine state law counts. United Health moved to dismiss under Fed. R. Civ. P. 12(b)(6), arguing relators failed to plead the elements of a “false certification” claim, they failed to plead any anti-kickback violations, and failed to adequately plead a conspiracy. Relators alleged that because United Health entered into a contract expressly certifying that it agreed with all “terms and conditions of payment,” they made a false claim when they submitted claims despite any one of the 11 purported regulatory violations alleged in the amended complaint. Rejecting relators’ express false certification claim, the court found “[not once in the Amended Complaint have Relators identified even a single claim for payment to the Government.”The court also held relators’ implied false certification claim failed. According to the court, relators argued that because United Health agreed to comply with all CMS regulations when it contracted to become a prescription drug plan sponsor, and because at times it was in violation of some regulations, it therefore committed fraud each time it submitted a claim for payment. The court found such a theory of liability overly broad. “If Relators’ theory were correct, the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,” the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government’s payment decision. While that argument is true, the court reasoned, “Relators must still show a claim . . . and [t]hey have not done so.” Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
    United States ex rel. Wilkins v. United Health Grp. Inc., No. 08-3425 (D.N.J. May 13, 2010).
    FCA claim alleging aggressive marketing tactics by health plan provider dismissed
    Publication: Health Law Week
    Date: Friday, June 4 2010
    The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans — including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss.
    The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator’s false certification claim. The relators’ theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants’ motion to dismiss was granted.
    Source: Health Law Week, 06/04/2010
    Copyright © 2010 by Strafford Publications, Inc. http://www.straffordpub.com / All rights reserved. Storage, reproduction or transmission by any means is prohibited except pursuant to a valid license agreement.

  3. After assisting many employees in my former position in Human Resources battle with United Healthcare over benefits they were entitled to, I find myself in need of assistance. UHC has denied claims stating: Provider did not submit w/in contract time. That was untrue so the next denial explanation was : Proof of timely filing was needed. That satisfied they stated coverage was not in place at time of service. Proof of coverage was submitted; they stated on the phone they would pay. The collection agency received documentation of this acknowledgment. Yes, it took this long. More than a year later, the promised payment was never made and UHC has started over making the same denial claims. Not only did they fail to provide the coverage p/contract and that they received payment for but now they have damaged my otherwise excellent credit. IS THERE NO CONSUMER PROTECTION?? HOW LONG WILL UHC BE ALLOWED TO CONTINUE TO VICTIMIZE MEMBERS? We are all stuck with the plans our employers offer.

  4. I have been with MDIPA for over 15 years and I had no problems with them. However this year United Health Care took over MDIPA. Now the problems begin. They call to see if I have another insurance company. They deny claims, the Co-Pays are out of sight, the
    cost of perscriptios have doubled. I have a procedure scheduled and I found out last night my Co-Pay is $150.00, I called UHC, they said it is spelled out in my new Policy on the last page of a 20-30 page contract!I should have done some home work before I signed up for another year with UHC/ MDIPA. MDIPA was a good plan before UHC took it over. Is there a good Health insurance company out there?

  5. I’m with you if any one wants to fight them. I suggest we bombard the call center with calls day and night until they have to pay some claims. They lie so badly, never return calls. Then they tell you to appeal it. I am bypassing the appeal and will call every day until they pay. The people there would get so sick of talking to the same people everyday, they might pay the bills theirself. It’s time to fight back- they can hang up on us, put us on hold, then we can call and do the same until they do what they said, pay for the covered services. UHC makes me sick!

  6. UHC is unbelievable. They harass my providers with constant demands for more information and recently, when I checked with one of my providers, they had not received any request for more information. This is for a bill of $800. In one instance they actually called another of my providers and asked…on the telephone…what her phone number was. So far this year I have received no payments, the only communications I have recieved are “requests for more information.” Or they have ignored my claims completely.
    What are they doing with all this money my employer and I pay for my insurance? Over the years premiums have gone up and service has gone down. We are paying ever more for ever less.
    Is there some way for consumers to band together to fight this expensive, unresponsive system?

  7. Amazing. One of the big-box home retailers that I recently began working for, with the initials “HD”, told me that I could sign up for Health Insurance, even if I only worked 12 hours a week! The provider? United.
    This morning, I was blessed to see the commercial promoting the new Michael Moore movie…Sicko… and United is mentioned in the 15 second “Blipvert!” (Yeah I almost exploded when I saw that)
    I reside in Massachusetts and a law was passed by Gv. Romney (who’s in the presidential race – sorta) mandating all residents to be covered by health insurance. What this is actually doing is causing Health Insurance companies to diversify and roll out individual plans. We all have to be covered by July. I would invite all of you who are interested in following the diversification of Health Insurance for the individual to follow what is happening in Massachusetts over the rest of the summer. And thanks for the comments on United, because I’m going to look up my own policy (and some plans are actually reasonable.)

  8. UHC has many ways to deny claims. Remember if your insurance is provided by your employer as part of the the health and welfare plan, then UHC is only the administrator and exempt from state law. The only way to get payment s for services may be to sue your employer.
    Also it appears in my market that the big discounts that are negogiated by UHC actually go right to their bottom line. Your copay should be based on the amt after discount, but what they do is obtain an illegal kickback without applying the discount to lower the co-payment.
    This entire setup is just like the entire protection racket in Chicago in the 1920’s. These guys will continue to fight for every penny.
    I believe it is time to set up a national heal care system without the insurance companies.

  9. United Health Care has been playing games with my claims. Everyone has been denied. They are using this tactic to make more money for themselves. If you are thinking of buying UHC insurance don’t.

  10. United Healthcare- I think they should pay the administrative cost for their errors when they become excessive and “abusive to the system”. In September of 2006 United began paying my claims at 100% of billed charges. To NO avail every claim had to be appealed and request that the process at the contracted rate. All of the first appeals show that they paid correctly and to keep the monies. If I were not an honest guy I would have done that and let them find these on their own. 6 months a 300+ claims later they started pricing the claims correctly. Now, even though it is my office making them aware of the overpayments, they are recouping all of the money I am telling them about. Not a problem if in fact I had not previously submitted a refund to them which they cashed and my account was sitting at –0-. Yes the Accounts receivables are out of control as the aging is increasing because I have to bring back and recollect on all of these accounts. To get a live person is an act of congress. When I get the people in another country I am told that they will send a message and someone will get back to me in 48 hours. Not sure what clock they are using but mine shows they are a few weeks behind in their call backs. I have left eleven messages and not a single person has returned my call. I finally did get through to a person (after the 15 minute wait) only to have them pick up the phone, tell me the computers were down, to call back in one to two hours then hung up on me. How nice is that??

  11. UHC has slashed my physician pathology laboratory fees almost 50% compared to two years ago, they are now paying me LESS than HMO rates for PPO patients (they say it’s my “contracted” rate, I never got an updated contract with those reduced fees; when I saw what they are now paying, I felt like I had been kicked in the gut…) AND, over the las two years, they have continually denied claims, and/or failed to process claims correctly; what recourse do we have, I have written the State insurance commissioner (California)–how are we physicians with a small business supposed to survive???

  12. Is it true that this past Friday UHC let go of ALL Pacificare’s Individual and majority of the Small Group Sales force? How are members being supported?

  13. First time commenter – but just experiencing deja vu – it seems United has had this problem for years – they’ve been nailed for denying claims without sufficient information before – and almost had selected HMO operations shut down due to this in some locations…the claims systems were highly efficient – but often wrong.

  14. You got space in your exam rooms for a puppy? I bet it relaxes the patients…
    And don’t worry, Subtle Sally will get it. She’ll see improved cash flow immediately. There will be great rejoicing. But she will chase you down to get those forms filled in right before the end of the month.

  15. Tom, it cost me a 20% increase in overhead just to read and understand what it is you’re proposing. Way too complex. Remember the KISS principal! I’m with Matthew. Just bring on the puppies.

  16. Sure you do! Until it comes time to clean up after him. Then what? Hmmmm?! I bet you give him right back to me.

  17. So, what would be nice?
    I could imagine one nice scenario:
    1) Based on past experience, we find that 75% of this
    doc’s initially-incomplete claims turn out
    eventually completed and valid.
    2) Pay the doc 75% of the claimed amount, and ask for
    more documentation. Hold the claim
    3) If you don’t get it, deduct the previously paid
    amount from the next check.
    3a) For extra credit: use a more complete kind of IBNR
    calculation that takes into account the “tail”. If
    you find out that 20% of the over 30 days claims
    are eventually found OK, then only deduct 80% from
    the next check instead of all of it. And so on until
    step 4.
    4) Do adjudication on what documentation you do get.
    After a year (or whatever) cancel the undocumented
    claims, and deduct the remainder.
    What do people think? Is this nice enough?

  18. $364,000 as a fine. Wow! That’s an amount equal to what their CEO Dr. McGuire makes in 5 hours of work!