The claims denial is for Advantage and for regular (non-Medicare) insurance. Supplements cannot deny claims unless Medicare doesn’t cover a procedure. So you should not run into any issues as a result of your Supplement being through UHC.
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No plan that is offered in my area had any coverage out of network. None. I looked.
We went with a PPO.
I can only hope that we have few health care needs before Medicare. It’s a horrible place to be.
And I have much more sympathy for those who don’t work for big corporations with great benefits. I knew we were lucky, I didn’t know how much until lately.
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This bears repeating
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When both of my kids had their wisdom teeth pulled (one had four and the other three…at the same time), my BCBS insurance, and I think it was the medical at the time…covered the extractions but not any kind of anesthetic. Now really…would anyone have three or four wisdom teeth extracted without anesthetic!
DS had a general, but DD elected for local.
We paid for it.
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I think there is a donut hole of sorts for midsized employers. Large ones can self-insure, and savvy startups can get better deals through companies like Trinet that offer group coverage at reasonable $$ because the insured pool is mostly younger dudes - ‘cause startups!
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I kept a notebook of my mothers medical visits, explanation of benefits from Medicare, explanation of benefits from her supplement…and any outstanding bills (there shouldn’t have been…any).
Remarkably, some of these doctors offices sent bills even though I had clear EOBs that said they had been paid in full.
So…keep an eye on the bills doctors send.
Also, my mother had a tendency as many seniors do…to pay bills without thinking first. She paid some bills before her supplement paid their share. It just about took an act of God to get that money refunded. When I noticed this was happening, I took over paying her bills.
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I’d rather not get into personal information about the specifics of the challenges with insurers, but one was many decades ago when they denied services for something our then toddler needed. They denied and stalled and when I asked for a doctor to doctor review, they admitted that they hadn’t had a doctor review the file as they had claimed. And they cover the services for adults, and when we diplomatically asked if they were discriminating against young kids, they finally approved and paid for the services.
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When the mandate to require insurance coverage was overturned, my BiL was relieved because he and his wife had chosen to not have any insurance at all when he had lost his job (they are in their 50’s). They didn’t want to go to the doctor lest it be revealed and they would be punished. They had no money to pay the premiums, so I get the decision.
But he had a massive heart attack, coded twice, ended up with a pacemaker. All without insurance. The hospital put them on a payment plan, wrote off some of the charges, and put a lien on their home until he found a new job. But they will be paying this off for the rrst of their lives.
All the choices are hard. All the advantages are for those with the money to work the system, and the time to do it.
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I think that’s always how it works with teeth extractions.
I had a tooth pulled as an adult. I want to be asleep as it was my back molar, insurance didn’t pay for the anesthesia.
It was the same when my kids had their wisdom teeth paid.
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As for clients, services that were preapproved were then denied after services were rendered. Then they tried bouncing the claims back and forth between different divisions, then claimed the claims and records were never received (all appeals were sent by certified mail). I had some contacts within the company who claimed they’d help work it through, and they did not. The patients tried to get assistance from their HR and benefits personnel, and we all had to file complaints with the insurance commissioners office. It took literally over 2 years of persistence to get these claims paid. As soon as they were paid I resigned from that insurance panel (and fwiw, yes those 2 patients had UHC insurance).
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There are even more stories, one personal situation that took a year and a half to get correctly resolved (this was with BCBS and I had been both a provider for them as well as having them as our insurance company). I could point them to their mistake (which again made a difference of a few thousand dollars). But it took a year and a half and finally getting our benefits person to help connect us to a BCBS senior manager to get it corrected. ). It started again with a similar claim 2 years ago, but we got benefits and managers involved sooner, so it took “only” about 6 months to get corrected. But- then they tried to do a claw back a few months later, claiming they overpaid. Fortunately I had the emails to/from the managers and reached out for help. It took another 3 months to get the letters demanding a refund to stop. Being in healthcare I have some knowledge of how to address these snafus. So many people do not, and simply pay bills that insurance should pay, or don’t get their erroneous eob’s/payments rectified.
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I have two to share:
One, my insurance paid my emergency room visit (and the ambulance, I think). The day after my visit to the ER, I found out that workers comp would cover - it happened at a school site I was volunteering at. Over several months, I found out that the hospital had been paid by both. In conversation with the hospital receivables department, I was told “We don’t refund the insurance company unless they specifically ask” (or something to that effect). I got my insurance on the line, and they said “They’re not supposed to do that!” All three of us ended up on a conference call. I think it got repaid, but after some back and forth, I needed to move on with my healing.
After my daughter was born, it took a few months to split the bills between existing insurance and the new insurance we went on about a month after her birth. In this time window, I made contact with a support person who was helpful in moving things forward. I think I had one more call to have with them, but, when I called, my insurance group had be reassigned to a different support group. Eventually they did pay their part, but as a new, first time mom, it would have been nice to have this be an easy step…
As far as the idea that people get bills dismissed if they don’t have insurance or have inadequate insurance, medical bills are still by evidence I can find, the largest reason or bankruptcy in this country.
Way back when my S was in kindergarten, there was a girl in his class with a little brother, really cute kid… At the time, my husband was a pediatric resident at the nearest Children’s Hospital, and he recognized the little guy because he’d been at the CH for a liver transplant as a baby. Everyone there loved him.
By second grade the girl was gone from the school. It turned out they’d lost their home because of the medical bills not covered by insurance and had to move in with family. No one should lose their home because their baby needed a new liver to live.
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That reminded me of another insurance story! Those readers who have been here forever may remember when my older s broke his leg skiing when we were visiting colleges for younger s . S was taken by ambulance to the little local hospital and then by a second ambulance to the bigger hospital around the mountain for surgery. The insurance company denied the second ambulance trip claiming it was a duplicate charge. Long story short, after many calls I finally got a wonderful claims rep names Shirley who not only got the claim correctly processed, she said that because his situation was an emergency they should have paid his hospital bill as in network and she got us a refund. She was wonderful. And she returned calls when she said she would (no others did that). She became my new best friend 
the company DH worked for at the time is a large, well known company that is self insured and had some dedicated number or something. Anyway I wrote a letter to the head of the company benefits department as both a member of the company family (user of the insurance) and as a provider for that insurer, singing Shirley’s praises. Apparently my letter ended up on bulletin boards all over their claims department (this is before it all got transferred offshore). She was wonderful and I could contact her when I needed any help with something, until my letter got her promoted!
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This is more of a hospital billing office story instead of an insurance story. When D was in high school she needed a major surgery and a week in the hospital two different times a year apart.
The second time I was just over the whole thing and wanted it done and over with. She was in the hospital for the last few days of one month and the first few days of another month. Her medical insurance changed on the first of the month that she was in the hospital.
I was very clear with the hospital billing office which days should be billed to which insurance. I wrote it down for them and gave them the paper.
I got a bill a while later for tens of thousands of dollars with no insurance payments listed. I promptly called the hospital billing office and asked them why the insurance did not pay. They said the insurance said they were not responsible. I asked them what days they had sent to each insurance. They had mixed them up and sent each insurance company the wrong days.
They resubmitted and I again received a bill for the full amount. I was again told the insurance companies each refused to pay for the days they were billed.
This happened a couple of more times.
I finally told the billing office to bill both insurance companies for the full thing and see what happened.
Each company then paid for the days they were responsible for and I got a much more reasonable bill.
Funny how things turn out when they are done right (or close to it).
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My D is dealing with this now. Before her small company chose coverage this year they confirmed that her PCP was in network. Then, 6 months later, she got a letter saying oh so sorry, we goofed, our mistake, your PCP is not in network and we don’t pay anything out of network, sorry for the inconvenience, pick an new PCP and reimburse us for the payments we’ve made to the PCP.
She’s trying to fight it.
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I’ve scanned through the posts, and we certainly have our own stories with medical insurance, but I think we are missing the elephant in the room: health insurance sucks because that’s what your employer (or you) paid for. Note that I am avoiding the discussion of a public option, because that’s not an option (and that’s an entirely different topic).
If you have UHC through your employer, they likely chose that because it’s often known as the cheapest option. It saves on their costs, and likely reduces your contribution. And if they deny service, they are labeled the bad guys, rather than your employer which paid for that level of service.
I was reviewing a summary of UHC financials. 2023 was a particularly good year for them, profit wise, compared to their long-term average (2024 was already on track to be lower). They have a few different businesses, but if we consider just the medical insurance part, in 2023 they paid out 83 cents for every dollar in premiums. We don’t have a detailed breakdown of costs just for the insurance business, but for the entire company, about 15 cents was allocated to operating costs, about 2.5 cents for interest and taxes, and 6 cents for profit.
I think there is a good argument to be made that a payout of 83 cents is too low, given that we are stuck without a public option. But if your company chose UHC, they should have known this when making that decision.
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Absolutely NOT true. I have “great” UHC insurance through my employer, $0 copay, low deductible. I had “great” similar benefit BCBS last year. High deductible is on the subscriber. No out of network benefits…that’s probably on the subscriber too, even though it’s underhanded. Unjustified denials are part of the business model, NOT a fault of the subscriber! It’s pervasive in this slimy industry. It’s how they make money.
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A couple of examples:
Several years ago, I was looking for a new endocrinologist. We lived in a different area at the time and while that area had a decent # of endocrinologists, pretty much all of them only knew how to handle standard hypothyroidism and type 2 diabetes.
I have a different endocrinological problem than that. Mine is rare enough that I’ve actually had the head of the department at a major medical center tell me that they’d read about people like me in med school. Um, great?
New endocrinologist was great. Awesome bedside manner, really on top of things. But her billing & office staff were incompetent. Dr ordered an ACTH stimulation test. This involves doing 3 identical blood draws within a relatively short period of time (at, like, time 0, I think 30 min later, and then an hour after time 0?).
Insurance company denied the 2nd and 3rd blood draws as duplicate claims. I called the billing dept many times, spoke with them on the phone, left messages, nothing ever got resolved. Meanwhile, the lab started sending me delinquent bill statements in the mail, threatening to send it to collections. Had to shell out >$1000 out of pocket for all that.
I never went back to that doctor.
Oh and on top of all that, on the day that I did this test, I had an abnormal reaction to the ACTH injection…basically had a mild adrenal insufficiency reaction. So I felt like I’d been hit by a bus, felt feverish (without having a fever), intense body aches, and had to take the rest of the day off of work in order to sleep for the next 6 hours.
A few years ago, a friend of mine got genetic testing for breast cancer and tested positive for the ATM gene mutation. She’s supposed to get alternating mammograms and breast MRIs every 6 months. She switched PCPs and was seeing a new guy, who was incompetent, had an ego, and didn’t listen to her. That Dr kept submitting the prior auth request to her insurance company incorrectly, not including the correct info explaining the reason for the screening tests every 6 months. So every time for over 9 months, she kept getting denials from the insurance company. Complaining to the doctor’s office went nowhere. The doctor was a jerk, actually told her once that he preferred patients who just took him at his word and never asked questions.
So she switched to somebody at a local cancer center instead. That provider knew exactly what to do, how to submit the prior auth in order to get it approved, and bingo, friend was finally back in business. Wasn’t the insurance company. It was the butthole doctor’s fault.
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My silliest medical bill was when D was hospitalized at age 20 months or so. Shortly after she was discharged, they sent me a bill for her BIRTH! I asked them to itemized what they were charging for because when her older brother was born 2 years prior, we had NO copay and the only thing we had to pay for was the tyvek suit for H to wear in labor & delivery, which he never wore and brought to wear for D’s labor & delivery (since it was unused—he actually wore it for D). The hospital said they didn’t keep itemizations for bills that old and I said I couldn’t pay without any itemization so they said to just forget it and I never got another bill for D’s birth.
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