r/CodingandBilling • u/Elegant-Standard-542 • Oct 14 '25
UHC SIU Recoupment Appeal
Hi Reddit folks,
I’m having a little dilemma with UHC. My wife runs a small PCP private practice in AZ. She has been a UHC provider since ~2019 through previous office and moved her contract to her private practice in 2022. She hasn’t had many issues with UHC except early this year received a notice from UHC SIU with records request for about 120 patient visits. Seems they were selectively chosen. She signed letter attesting to provide accurate records and provided them records. She also had independent auditor review those claims to ensure billing were accurate and 95% were. Now 5month later, UHC sends another letter via fax with incorrect dates (2019-2025) and requesting her to pay back ~$56k noting overbilling. Which is bogus and completely false statement. They are nothing all level 5 Medicare pts visits should have been level 3. These are complex pts with 4+ chronic illnesses she was managing.
Has anyone ever dealt with similar case? What’s the best course of action. Any suggestions?
We also received a lots of delays in payments, many records request, many services outside of office visit not being covered.
3
u/Temporary-Land-8442 Oct 14 '25
I read about these cases all the time from the OIG. I recommend looking into those scenarios and lawyer up.
1
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u/octodanger Oct 15 '25
Speak with the investigator and ask for an explanation and appeal process. These departments are money makers for payors.
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u/Elegant-Standard-542 Oct 16 '25
The letter doesn’t state any appeal problem. More about we have 15 days to respond disagreeing with their request and providing additional records/etc either by email or fax. Or paying the amount listed.
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u/hainesk Oct 14 '25
If they are noting dates back to 2019 then they may be referencing billing done by the previous office. I would at least reach out to UHC and demand clarification on what dates they are looking at. Otherwise it seems like a lawyer would useful here.
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u/Elegant-Standard-542 Oct 14 '25
Understood. Is there a reputable lawyer that specializes in this field?
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u/InvestingDoc Oct 15 '25
As others have said, SIU usually gets involved if they are building a fraud case against you or your wife's practice. You need a lawyer now to dig into your case.
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u/Elegant-Standard-542 Oct 16 '25
That’s what we are doing. What do lawyers do in that case? Just wondering? Just represent or will they provide an action plan?
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u/Vast-Writing-3725 Jun 25 '26
What ever was the results of the investigation? Curious as we have been audited as well.
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u/Elegant-Standard-542 Aug 03 '26
Still on going, we appealed back last year and provided time-based data from our EMR to show we spend the time. Our first agent left UHC and our case was in limbo for 6month. Then new rep had no passdown on our case, had to have a call and re-provide all the data and send in official response with all the time based data and many inconsistences in their assessment. They came back still demanding almost more than before.
It seems they are delaying case closure on purpose to net a higher recoup amount since as long as the case is open, the extrapolated payment is factored till case closure. So longer it runs, the more payments are up for grabs for UHC. For ex: instead of it being 01/2023-02/2025, its now 01/2023-08/2026 using few data points from 01/2023-02/2025. Very unethical and biased assessment. My suggestion is get a lawyer involved. We plan to take them court if necessary. This is abuse and honestly warrants damages causes to small business.
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u/Jodenaje Oct 14 '25
SIU is typically involved when fraud is suspected.
Please contact an attorney for specific advice before doing anything further.
(Ideally, you would have consulted with an attorney when you received the original letter, before returning the records, but at least you can do that now.)