Florida is UnitedHealthcare’s 2nd largest market. What that means for insurance denials. Experts say seniors need to be particularly aware of their rights as they become increasingly more likely to have their claims denied.
About 4 million people in Florida are insured by UnitedHealthcare, a company facing backlash after its CEO was shot to death in Manhattan, followed by public outrage over its pattern of coverage denials.
Florida represents UnitedHealthcare’s second largest market after Texas, providing coverage through employee plans, the Affordable Care Act open marketplace, and Medicare Advantage plans.
This week, the insurer’s prior authorization and coverage denials in the state drew the same anger and frustration seen nationwide on social media in the wake of the shooting. Florida lawyers, insurance advocates, and medical billing experts say being informed about UnitedHealthcare’s practices, making smart choices, and fighting back is critical, especially now that the insurer uses sophisticated artificial intelligence (AI) to deny approvals and claims. According to consumer research site, ValuePengiun, UnitedHealthcare denies claims at a rate nearly double the industry average and now faces a barrage of lawsuits, including hundreds in Florida.
How to make an appeal
Donovan said patients denied prior authorization or payment should dig through the insurer’s denial letter to find instructions for the appeal process.
“Your denial will include details as to why they are making this decision, so you have to counter that with the facts that support your argument,” she said.
The Patient Advocate Foundation has sample appeals letters on its website.
When planning an appeal, document every step of the process, advises Russel Lazega, a Dania Beach insurance claims lawyer.
“Don’t treat an internal appeal to the insurer informally,” Lazega said. “A lot of people call and talk to the insurance company and don’t document it.”
Documentation should include emails from the insurer to the patient or from the patient to a doctor or hospital.
“Gather a direct response to their denial from your doctor and add your additional medical records to it,” Lazega said.
Sometimes, that documentation is enough to win an appeal.
If unsuccessful, the next step is an external appeal to a company hired by the insurer. “It’s important to have your documentation in the file. Any documentation about your appeal won’t be looked at unless it’s already in the file. Adding it later is hard, so don’t give the insurance company that technical advantage,” Lazega said.
The final step is federal court.
Lazega said people in life-or-death medical situations tend to go this route. The patient pays legal fees, not the insurance company.
“UnitedHealthcare approves and pays about 90% of medical claims upon submission,” UnitedHealthcare said in a statement provided to the Sun Sentinel. “Importantly, of those that require further review, around one-half of one percent are due to medical or clinical reasons. Highly inaccurate and grossly misleading information has been circulated about our company’s treatment of insurance claims.
“We do not use AI to make adverse coverage determinations. Coverage decisions are based on CMS coverage criteria and the terms of the member’s plan.”
Does that mean each AI determination is reviewed by a human?
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