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Approved for Surgery but Denied Payment the Day After the Surgery Was Completed

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By Tony - 03/02/2016

WAUSAU, WISCONSIN -- In the Summer of 2015, when I was 56 years old, I spoke with my personal provider during a scheduled physical about some difficult and painful varicose veins I had in my right leg which were preventing me from exercising, having the ability to regularly sleep sufficiently to feel well rested, and which significantly contributed to an excessive weight gain. I was referred to a local surgeon by my provider and I verified that he was covered by my health insurance (UMR) to provide me with services with a UMR Insurance Representative. I have a family history of severe varicose veins along with a familial history of vascular and heart disease.

In October 2008 I sustained a myocardial infarction which resulted in surgery, hospitalization, and extensive cardiac rehabilitation. In 2010 I had similar veins in my left leg which were ablated through a radiofrequency ablation through the same surgeons office by another surgeon at the same Outpatient surgery center and called UMR and received no difficulty in having the procedure costs paid for. The employer and insurance through that employer that I had during the first surgery was/is the same as for the second surgery.

I informed the surgeon as I had the primary provider that I was intending to retire at the end of 2015 and that I wanted to take care of any significant medical issues prior to retiring. The surgeon agreed that this was a wise way to proceed and he informed me that 3 visits with him for visual assessment and a vascular ultrasound and photographs were necessary to meet the standards of the insurance company. On October 24th after the 3 visits with the surgeon and the vascular ultrasound and photographs were completed, the surgeon's office submitted the information to UMR Insurance for Pre-determination of need and payment of benefits.

The surgeon's office received a letter indicating that there was no need for this and that the procedure was covered under my employer's insurance plan with the surgeon and the surgery center I intended to use. Approximately a week and a half prior to the intended surgery date (November 23rd, 2015) I contacted UMR Insurance and spoke with a representative. During the contact I made it very clear that if the surgery wasn't going to be covered by UMR insurance that I would have to postpone it until such time that insurance would cover it because I did not have the available funds to pay for the procedure.

I repeated that I did not have the available funds to cover the costs of the procedure several times and each time was told not to worry. The representative assured me that the procedure was a covered procedure by my plan and the only question she had was to ask me if the surgery was going to be done in a hospital or in an outpatient surgery center. When I told her an outpatient surgery center she again reassured me that the procedure, the provider, and the intended outpatient surgical center were part of my plan coverage (indicating that it would be covered) and that I should go forward with my tentative plans for the surgery.

On November 24th (the day after the surgery was completed) a letter was generated by UMR insurance which I received the following Friday which was the day after Thanksgiving 2015. The letter indicated that the size of the vein which ablated was not 5.5mm at the saphenofemoral junction (I later found out through the surgeon's insurance liaison that the size was over 5.3 at that junction and within 2 inches below the junction it was 5.7mm) and as such that the procedure and its costs would not be covered to the cost of $16,520.

The surgeon's liaison also indicated that neither she nor the surgeon were aware of this measurement requirement at the point where it was identified. I have submitted the above information to UMR insurance along with a request for an appeal and have made numerous telephone calls to the UMR Representatives to be told that it is being reviewed and that the representative would get back to me which they never did. I have on more than one occasion requested that I be sent a written response to my appeal and I have only received an explanation of benefits notice denying my claim stating that it was not a covered benefit under my plan.

My last telephone call to UMR last week (Feb 26th, 2016) had me talking to a UMR representative, after waiting on the phone for 10 minutes who then hung up on me after she said she was going to transfer my call to another young lady who I had talked to 1 1/2 weeks earlier who said she would call me back in 2 days and in 1 1/2 weeks did not call back. The representative then later called me back threatening that she wouldn't be able to help me if I hung up on her again. That representative stated that unless I submitted another appeal there was nothing they could do.

I informed her that in January 2016 I had sent in an appeal. She stated that because my initial appeal was received while the procedure and benefits were being reviewed another appeal would need to be submitted. I have sent this in as requested on February 27th, 2016.

To this date the insurance, although they have refused the claims for this procedure have covered/paid approximately $800 and negotiated a $2000 reduction in the surgeon's costs and paid a little more than $590 to the outpatient surgery center and negotiated a $3452 reduction leaving me with $8168.00 to pay out of my limited monthly retirement pension. This process has caused me, my family, and my surgeon more than a little frustration.

They Are Horrible In Our Opinion- Pray You Never Need Them!

ST JOSEPH, MISSOURI -- I cannot understand how UMR gets by operating as they do. One hand never knows what another is doing. Every time you call in, a different person. One dept. cannot or claims they cannot view what another dept received. You get transferred and transferred. Promises NOT kept. No one has the correct answers. Some of the workers cannot read a description or choose not to. They appear to stall and use the worse tactics to avoid paying claims.

We send in documents and send them in again and again, UMR says they didn't get them. When I finally insist I have already spoken to another representative who had already admitted they did have it, they "suddenly" find it. I have come right out and told them that I think they do these tactics to keep from paying legitimate claims. I think it is horrific for them to put people

through this at a time when you are dealing with illness and accident.

Our daughter was involved in a terrible accident. She is disfigured for life. While we are trying to handle this, we have to fight and fight and argue and argue over each and every aspect of every single claim. What is the point of pre-authorization if the claim is then denied after it is fully approved. They kept saying we had met our max out of pocket expense for this accident, then make us jump through more and more hoops and then deny the claims anyway.

Our daughter is only 14 and has sank into a deep depression. She is traumatized by the event. While we are dealing with all that, it is upsetting and unfair to have to fight each and every single charge with the insurance company. My husband has served the State of Missouri faithfully for going on 20 years, it is a travesty and I mean a TRAVESTY to have no choice but to use this company! They offer NO dental and NO vision either in our area and never have! It is a TRAVESTY. I pray some insurance commission reads all these complaints and puts a stop to their ways as they put us through pure hell.

Cheating members via denials of benefit coverage and contradicting language in policy

By LenaSunShine - 08/04/2010

SALT LAKE CITY, UTAH -- UMR is a subsidiary of United Healthcare and is contracted with my spouse's employer to administer the company's healthcare plan. Last year we had constant problems with their processing our claims incorrectly. I had to make my own spreadsheet and track all of our bills and payments to ensure we were covered properly, and I spent hours contacting UMR to straighten out their mistakes. Then this year, in addition to a medical provider still owing me over $600 I've yet to get back and it was due to a mistake on the part of UMR, at the very end of the year, for the first time, UMR refused to pay for my covered pap-smear and mammogram.

I had them at the same time of year I normally do to ensure there is a full year between them, and I'd met my $2500 deductible several months before. Yet, they refused and claimed a new rule to our coverage that I am still covered 100% for a pap, mammogram, and well adult exam and labs regardless of whether I've met my deductible, but the well-adult benefit is covered only up to $500 and I'd already used it for the year.

For the first time they stuck the pap and mammogram into the well-adult exam category and said I had to pay because I'd used my $500 allotment for the year. One exam with accompanying blood lab work, a pap, and a mammogram cannot even begin to be covered by only $500, especially in Alaska where medical care costs 30-55% more than other places in the country. What a scam!

In addition, blood work I had done that week, not even related to the pap and exam, they refused to cover for the same reason, but my coverage contract states that I have 100% coverage for everything after I meet my $2500 deductible.

UMR/UHC ended up costing us an extra $3000 out of pocket at the end of the year and didn't even bother to respond to my appeals! I did get one email after I appealed a second time and forwarded the information to my husband's HR office, and in the email they asked me to be patient for a couple of days while they examined my file, and then I never heard from them again. That was last winter and it is now August.

By Dolfan1972 - 01/10/2011

I work for a Health Plan in Arizona, and have had UMR for 2+ years. I'm a single male and don't go to the doc or hospital very often. Well that being said in 2010 when I did have to go to the Dr. and found I needed to have a minor surgery, I was OK, let's get it over with. Well UMR has denied not only claims to see my PCP, they have denied EVERY claims filed that year. And now my premiums have gone up (get this) 300% to be under the same plan and to add my son. Yes I was paying $30 (monthly) now. I am paying $167 a pay check! Who are these people and why do they call themselves an Insurance company.

I vowed to not visit any hospital or Dr this year because I don't want to end up with over $3000 in medical bills this year, as I can't afford the ones from last year. As for my Son I am scared to death what would happen if we had to go to the Dr. At this point I now understand whey people stop working and get on Medicaid (AHCCCS) because its cheaper than working for your insurance.

I work my butt off to pay my Rent, and Insurance. UMR and my job just made it 300% harder to live, but what can I do? The State of Arizona is giving Medicaid out to everyone left and right. But because I work for my money I can't even get assistance. But if I stop working, I will get free medicaid, free prescriptions, unemployment, section 8 rent, food stamps, child care, cash assistance, etc. Why work if I just stop working, they just give me everything I work for. for free.

If you are interviewing with a company that uses UMR Runaway fast!

By Remain - 06/11/2013

My daughter had a psychiatric emergency - I drove her to the ED of the hospital I work for knowing that insurance would pay better, but there wasn't a psychiatric bed available in our facility. After finding an "in network" facility, the ED staff social worker called a transport service to transfer her to the other facility (85 miles away). Once the claim for the "transport" was processed it processed as out of network hitting a completely separate deductible making the $1,400 bill my responsibility. At no time during the visit in the ED did anyone give me an option on how to get my daughter from hospital A to hospital B.

After finding this out I looked up the covered ambulance companies, of the 3 for the entire state none of the phone numbers worked after hours. 1 of the numbers never worked, 1 company didn't service my part of the state, the 3rd was considerably cheaper which brings up a whole other issue of collusion by my employer, the insurance company and the ambulance service.

How could they not know that the insurance company that they were going with for a 2nd year does not have the only ambulance service that they call in network? Since we are self insured it's a convenient way to pass the cost on to the employees.

Category: Insurance

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