If you’re currently involved in a health care coverage lawsuit or recently received an insurance claim denial from United Healthcare, then the staff at Stop Insurance Denial Law Firm are here to help. They have the legal experience to fight for those sufferers who are in desperate need of immediate insurance coverage that they paid for either through personal or work-related policy agreements. Stop Insurance Denial Law Firm isn’t afraid to take on large insurance companies like United Healthcare to show how their unsavory business practices have compromised their client’s lives.
Who is United Healthcare?
United Healthcare is a Minneapolis-based insurance company that operates under the umbrella of the UnitedHealth Group. They have over 45 million policyholders in 23 state exchanges as members have broad access to a network of physicians and hospitals nationwide.
United Healthcare is best known for offering extensive employee and individual health care plans that have a consumer-orientated benefit. They offer a wide variety of coverage that meets the Affordable Care Act (ACA) guidelines as some of those options include insurance policies that are tailored for those with a specific medical condition.
However, United Healthcare has been involved in several insurance benefit conflicts that have escalated into civil lawsuits. Most of the disagreements center on the insurance provider’s failed attempt to cover the agreed-upon benefits found inside the policy agreement.
Unfortunately, in today's world, our health care system has too many flaws to properly care for the immediate needs of their members. We have all seen or read the documentation of personal accounts of how individuals have fallen through the cracks of the insurance claims process. Too often, United Healthcare failed them in a time of need. The dispute begins and ends with the denial of necessary medical treatment.
Independent Studies of United Healthcare Medical Services
Recent independent studies on the medical services offered by United Healthcare showed that it wasn’t worth paying one of the highest premium prices on the market today. Too many cases showed how United Healthcare failed to give final approval on immediate surgery until the last possible moment. Often, the lead physician submitted the required paperwork weeks in advance of the surgical date. United Healthcare uses every resource available before approving an insurance claim. If denied, the best option left for insurers was paying for the surgery out of their own pocket.
Other unsavory business practices by the insurance provider include increasing premium rates to those policyholders on Medicare. Most policyholders received a bill for each doctor’s visit or having to pay an extra $50 for lab work. This reckless action caused physicians to refused to accept United Healthcare coverage in their private practice. They would instruct patients to gain prior authorization from United Healthcare before scheduling an office visit. All of their complaints center on the primary insurance provider’s failure to reimburse them on an in-patient examination.
The studies concluded that United Healthcare coverage failures were calculated and systematic, which has forced many current and former policyholders to file civil lawsuits for damages. All court findings showed how United Healthcare improperly handled all insurance claims by receiving possible kickbacks from several pharmaceutical companies.
United Healthcare Defrauding Their Benefit Plan
A civil lawsuit filed last August alleged that United Healthcare breached their contract with several union’s employee benefit plans by paying out fraudulent, illegitimate claims. The insurance provider’s actions cost union benefit plans over $10 million in payouts on claims that were excluded under the originally agreed coverage.
The attorneys for the union felt the goal of United Healthcare was to stop payment on fraudulent insurance claims in order to get reimbursement on as many as possible to gain a profit from the various pharmaceutical companies. Their actions to deny insurance claims aided these companies to gain a profit by raising the prices of prescription medication.
The hope for this civil lawsuit was to establish better guidelines that required more transparency for the pricing of all prescription medications. By winning the verdict, the law could challenge the way pharmaceutical companies profit from the marketplace.
A case of this nature can assist in changing the plan of attack against United Healthcare, who has been involved in several decade-long civil lawsuits that allege them of purposely withholding insurance claims in order to meet their financial objective. In those cases, many of the sufferers showed how United Healthcare covered only a portion of their medical bill, with the remainder being paid by the patient.
In last August's lawsuit, the union’s attorneys show an elaborate plan designed by United Healthcare that failed to detect fraud and abuse of the system, thus allowing them to reclaim overpayment for those approved insurance claims. The more prescription drug claims approved, the more money United Healthcare made in their fiscal year.
Typically, they would spread out the number of claims approved, which allows pharmaceutical companies to lower their prices on prescription drugs and give United Healthcare a wider profit margin.
According to the lawsuit, this plan allowed United Healthcare to reduce the volume of approved insurance claims in other areas of medicine. The sufferers of those ailments had little chance of gaining an appeal to an insurance claim denial from United Healthcare because the company chose the arbitration process.
The Denial of a Health Insurance Claim
When a health insurance claim is denied, the insurer's only options are to pay claim privately, appeal the denial decision or rescind the insurance policy altogether. The latter is also known as post-claim underwriting.
Insurance providers like United Healthcare, often deny a claim by citing a provision that was available in policies for years was suddenly omitted from the coverage plan without any notice. Too often, claims reviewers will look for obscure reasons to deny an insurance claim such as referencing an honest mistake on the insurance claim form as the basis for the denial.
Hiring an attorney to appeal your insurance claims denial is a smart move as they will advocate on your behalf by challenging United Healthcare to uphold the state's insurance and consumer protection laws. Their experience can show how a denial of an insurance claim can prolong an illness or even exasperate a diagnose into a serious medical condition.
The Tactics Used to Reject Insurance Claims
Often, the interpretation of the fine print found on insurance policies is the main source of why most claims are denied, especially in the area that pertains to how coverage benefits are paid. Many in the legal industry believe insurance providers have become "masters" in denying claims. Some of the reasons they provided for rejecting insurance claims include:
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the coverage requested isn't provided in the insurance policy agreement
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questioning the necessity of the treatment
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declaring the medication as an "experimental" drug
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diagnosing your ailment as a pre-existing condition
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creating unnecessary delays in processing the insurance claim
A new tactic used by insurance providers to reject claims is tracking a policyholder's social media accounts and using their own words against them in a health care coverage denial letter. In a possible civil lawsuit, insurance providers will then use this personal information to question the mental state of the insurer at the time of their illness. It's a complicated process that repeatedly shows how the insurance industry fails to protect their members when they're sick or in need of immediate assistance. Often, their actions do more harm than good.
The denial claim rate is increasing with each passing year, and in some cases, United Healthcare might have been correct with their original assessment. However, too often, they were incorrect in their final ruling, which causes hardship to those individuals who were denied use of their health care benefits.
This leaves insurance providers with a bad reputation because current policyholders are confused in what type of health coverage they actually purchased in their original policy agreement. In the end, we have seen or heard too many sufferers fall into financial disarray because they never received the proper support needed from their insurance provider.
Federal Investigation Into United Healthcare's Unsavory Business Practices
The United States Department of Justice (DOJ) opened a federal investigation into United Healthcare business practices as being fraudulent. According to the guidelines of the investigation, the DOJ was able to show how United Healthcare took measures to increase patient's risk scores that allowed them to deny insurance claims and force policyholders to pay for required medical procedures that weren't covered by their policy.
The investigation confirmed that United Healthcare upcoded data that created fraudulent documentation for policyholders to submit for approval. This would allow the insurance provider to refuse a previously filed insurance claim because it failed to have the false information inside. Specifically, a diagnose without complication had a much lower risk adjustment than a diagnose with complication.
According to the DOJ, in some cases, it meant a $3,000 difference in billing. The evidence introduced from the investigation showed original diagnoses would reduce the risk adjustment. However, a new diagnose code submitted did increase the cost, but the coders failed to delete the old diagnose from all medical charts.
The reviewing process of insurance claims became very profitable for United Healthcare as they charged $30 for each review that resulted in an average of $450 of additional payments from each member. Physicians received a small fee for reviewing medical charts in an insurance claims case. United Healthcare gained their cooperation by initiating an incentive program that encourages physicians to see patients more frequently throughout the year.
The DOJ concluded their final rulings had more revenue impact than a clinical impact on patients as they ignored their actual medical conditions because the charts were over-coded. This standard practice generated more than $100 million in profits for United Healthcare annually.
Civil Lawsuit Against United Healthcare
United Healthcare operates one of the country's (Medicare Advantage) largest private Medicare insurance (19 million people enrolled) programs, but a recent civil lawsuit contested in the state of Wisconsin alleged them of abusive sales tactics to avoid losing state and federal government bonuses.
The suit was filed by United Healthcare sales representatives who accused their employer of keeping a dual set of sales records that hide customer's complaints against the company's services from becoming public. These acts of deception encouraged enrollment fraud by sales reps in order to collect bonus payments from the government.
United Healthcare was aware of this misconduct and encouraged employees to be more "intentionally effective" by forging signatures on enrollment forms or bribing individuals with iPads if they sign up for Medicare Advantage and stay enrolled in the program for six months.
An internal investigation was conducted by United Healthcare, but their findings proved these accusations to be inconclusive. However, the company did fail to report the accusation to the Center For Medicare & Medicaid Services.
Hiding these complaints from government officials helped to avoid United Healthcare losing its high ranking on the government's quality scale. The company's ranking was a key marketing tool for adding more members to the program. The more users signed up, the higher the bonuses that were paid out by the government.
The money paid out to United Healthcare was $1.4 billion in bonuses as all were based upon the company's rating and ranking. Thus, a judge ruled that all Medicare Advantage members had the right to seek damages against United Healthcare for all insurance claims denials.
Why Appeal an Insurance Claim Denial
By appealing an insurance claim denial, you are challenging the legality of a provider's authority to deny coverage benefits that were originally agreed upon in a signed policy. The importance of the appeals process is getting this type of treatment or medication on public record for other sufferers seeking a cure for the same illness.
A written appeal is the best source to get a full review of your denied insurance claim. You want to provide a brief history of your illness by offering the original diagnosis and treatment history, which should include all prescribed medications. it's important to summarize all correspondence with your insurance provider, and that should include quotes from the denial letter sent from them as well.
Finally, your closing argument in an insurance claims denial appeal should offer reasons why your provider is wrong with their original assessment. You must address their specific concerns with your insurance claim. Your provider may argue that despite the medication or treatment was Food and Drug Administration (FDA) approved, it may not be the right choice for your medical condition.
You will need to counter their argument by offering more clarification from recent medical studies that better support your insurance claim. Try securing letters from other sufferers of the same medical condition as they can offer a candid account of their time being treated with the approved medication or process.
Why You Need an Attorney
Health care insurance is supposed to be our safety net. It's our lone defense against the unthinkable. When an accident occurs, the first call made is to our insurance agent looking for immediate assistance. It's a person's security blanket when they're injured as the benefit coverage should help to keep their finances in order.
The sad reality of today's health care industry is medical expenses do add up very quickly. This becomes burdensome for a sufferer when an insurance provider like United Healthcare fails to pay on a legitimate medical claim. Thus, the end results put added emotional and financial stress on one's family.
A denied insurance claim may not affect treating a minor ailment, but when the treatment is critical to combat a life-threatening illness, then challenging the authority of an insurance provider should become your top priority.
If you're currently involved in a health care coverage dispute or recently received an insurance claim denial, the staff at Stop Insurance Denial Law Firm are here to help. They have the legal experience to fight for those sufferers who are in desperate need of insurance coverage that they paid for either through a personal policy or within a work-related coverage plan. They aren't afraid to take on United Healthcare insurance company in a court of law on the behalf of their clients.
The concept of overturning a denied insurance claim can be extremely difficult, often quite frustrating and very time-consuming. Unfortunately, those in need of health care benefits are incapable to fight the establishment because they lack the strength and stamina needed to put up a good defense. Often, once the insurance claim is denied, sufferers cannot muster enough energy to continue the fight, thus allowing United Healthcare to grow their bank accounts with premium payments and non-payout of supposed benefits provided.
Find a Legal Team Near Me
Never let these insurance giants get the best of you. Together with Stop Insurance Denial Law Firm, take United Healthcare on to fight for your health benefits. Their legal experience will guide you in the right direction to gain a fair settlement for a "bad faith" coverage agreement with United Healthcare. Plus, the majority of the staff have worked directly with multiple insurance providers on prior cases, so you have an excellent chance to secure a fair settlement.
Policyholders who have their insurance claims denied do have an option to get immediate results that will ultimately gain them the coverage they need the most. The Stop Insurance Denial Law Firm team has legally fought with United Healthcare in order to change the way they respond to health care claims and the type of medical condition they will provide under the coverage provided. If you were treated unfairly by an insurance provider, contact our team today with all of your legal questions or schedule a free consultation meeting at 310-878-1771.
