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UnitedHealthcare taught us ways to deny claims: Former employee
- Thread starter Duaine
- Start date
I have seen 3 different videos of her story, all slightly different, and some things do not add-up for me. My feeling is that at best she is being biased toward her side of the story, and at worst she is outright lying. Disclaimer, I have been a group benefits wholesaler for 42 years and specialize in self-funding.
In another video she explains that she works for UMR, which is the self-funded arm of UHC. Consider the following statements she has made.
1. "We had to memorize 1,000's of plan designs". While it is true that they may have been managing this many plan designs, it is doubtful that she was required to memorize them. It is all computerized. Even before computers automated all of the claim payor work, a claim payor would not have been required to memorize them.
2. She states that at certain times there was not sufficient amount of dollars to pay the claims that a member was calling her about. OK, that may be true, but in a self-funded plan that is usually not a carrier issue but rather the employer not funding the plan.
3. In another video she discusses how she was given a pot of money, $400,000 from which she could pay any claim(s) at her discretion. In this video it was the situation with the pancreatic cancer family, she went into their claim and paid it. Then logged off and quit. Very highly unlikely that she would be given the authority to spend that large of an amount at her discretion after only 9 months on the job.
4. Since the group is self-funded where did the additional $400k come from to pay discretionary claims? She is saying that it came from UHC. Why would UHC give a self-funded group monies to pay their claims? And, if in some fantasy world that the UHC did give her money to pay claims of self-funded groups this would be magnanimous of them and would be undercutting her claim that UHC does not care.
In another video she explains that she works for UMR, which is the self-funded arm of UHC. Consider the following statements she has made.
1. "We had to memorize 1,000's of plan designs". While it is true that they may have been managing this many plan designs, it is doubtful that she was required to memorize them. It is all computerized. Even before computers automated all of the claim payor work, a claim payor would not have been required to memorize them.
2. She states that at certain times there was not sufficient amount of dollars to pay the claims that a member was calling her about. OK, that may be true, but in a self-funded plan that is usually not a carrier issue but rather the employer not funding the plan.
3. In another video she discusses how she was given a pot of money, $400,000 from which she could pay any claim(s) at her discretion. In this video it was the situation with the pancreatic cancer family, she went into their claim and paid it. Then logged off and quit. Very highly unlikely that she would be given the authority to spend that large of an amount at her discretion after only 9 months on the job.
4. Since the group is self-funded where did the additional $400k come from to pay discretionary claims? She is saying that it came from UHC. Why would UHC give a self-funded group monies to pay their claims? And, if in some fantasy world that the UHC did give her money to pay claims of self-funded groups this would be magnanimous of them and would be undercutting her claim that UHC does not care.
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Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022
Virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This contrasts with traditional Medicare, where only a limited set of services require prior authorization. Prior authorization requirements are intended to ensure that health care services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization and lower costs. This may contribute to their ability to offer extra benefits and reduced cost sharing, typically for no additional premium, while maintaining strong financial performance.
Some lawmakers and others have raised concerns that prior authorization requirements and processes, including the use of artificial intelligence to review requests, impose barriers and delays to receiving necessary care. In response to some of these concerns, the Centers for Medicare and Medicaid Services (CMS) recently finalized three rules. Among other changes, the three rules clarify the criteria that may be used by Medicare Advantage plans to establish prior authorization policies, streamline the prior authorization process for Medicare Advantage and certain other insurers, and require Medicare Advantage plans to evaluate the effect of prior authorization policies on people with certain social risk factors.
[EXTERNAL LINK] - Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022 | CSG Actuarial
