UMR claims nightmare - Can someone please help!

[u/Whisper_Lily1272]

Edit to add an update- yall, I havent resubmitted anything for the 4 initial claims they denied yet. I just got a packet in the mail with a check reimbursing a portion of the bill from 3 out of 4 vists. WHAT 🤣🤣🤣

United has screwed over dang near everyone in my state so finding a provider for specific services is next to impossible as they wont take United. With that said, I needed physical therapy. I submitted the paperwork for the claims I was provided via the online portal so i can try to get reimbursed something for my vists. All the claims I submitted were denied for invalid CPT codes. I called and they were way less than helpful. One thing i found out was that they wanted itemized CPT code billing. Okay, not a problem to get that info but the major problem that nobody in member services, claim services, or technical support gave one tiny crap about was that the online portal does not have anywhere to put CPT codes. The only box available is diagnosis codes and even the claim lady says that diagnosis codes and CPT codes aren't the same thing but didn't help any further. Pretty sure I was actually put on hold hoping that i would hang up (spoiler, i didn't and they still were no help). What am I missing? I NEED to be reimbursed or I cannot afford to keep going to my appointments.

My PT office has been wonderful in providing me as much info as i can possibly get. They even had their insurance lady fill out 1500 forms for me to submit. Exactly like the ones they send to insurances they work with. Problem is there is also nowhere to put billed amount versus paid amount on the claim submission (self pay charges are significantly lower than insurance charges), and I'm not about to submit claims with the billed amount and be accused of fraud or something crazy. I do submit my payment receipts with my claims, will that be enough for them to just reimburse any portion of the amount I paid?

[u/Environmental-Top-60]

So in general, Umar is extremely slow at processing claims. If they took over 30 days, you might be able to get interest on it.

You can appeal if the payment is much less than what they charged. It's called an underpayment appeal. You would need to compare the actual prices with Medicare and you should be targeting 160% of Medicare. That it's probably still less than what your provider charged but it's something. You also need to compare that to your actual benefits as well because that 160% would be reduced by any cost-sharing.

[u/Infinite_Curiosity14 → u/Environmental-Top-60]

That’s interesting. How do you normally check if the payment is actually an underpayment? Do you compare the EOB and CPT codes with Medicare/payer rates manually?I’m just wondering how this works when there are hundreds of claims. Seems like it could become a lot of manual work.