Up until DOGE fired me in February, I had federal government health insurance through GEHA, which unfortunately uses United Healthcare as its network and claims processor. (For the record, when I first enrolled with GEHA they used Aetna, but then they bait-and-switched to United at the start of the next plan year, and it was too much hassle for us to switch our insurance.)
A few months ago I filed a claim with GEHA for one of my kids’ therapy appointments. When I received the Explanation Of Benefits (EOB) for the claim, it said that I had received a “discount” of $26.45 for each appointment. Next to the $158.70 total of the “discount” for all of the appointments, the EOB said, “Your plan negotiates discounts with providers and facilities to help save you money.”
Except my kid’s therapist isn’t in the United Healthcare network, has not signed any sort of contract with United Healthcare, and has not negotiated any sort of discount with United Healthcare.
And this supposed “discount” that I was getting because of the nonexistent negotiation? Well, I had already paid that money to the therapist; since they’re out of network I pay up-front and then get reimbursed by the insurance company.
Looking more closely at the EOB, there’s some illuminating fine print. There’s a “reason code” associated with each of the therapy appointments with a “discount”. At the bottom of the EOB in small type the same reason code is printed with this explanation next to it: “The amount billed by your provider exceeds the reasonable allowable amount. If the provider bills you more than the total you may owe, please contact ClearHealth at 888-550-8910. Please refer to Claims and Appeal Procedures in your Benefit Booklet.”
So, United Healthcare has unilaterally decided what the “reasonable” rate is for my kid’s therapy and decided they’re not going to reimburse for anything above that “reasonable” rate. For the record, the amount they were charged is completely in line with what is typically charged for that type of therapy in the Boston area, but it shouldn’t matter; United Healthcare doesn’t get to decide what providers they don’t have contracts with charge.
The “discount” the EOB is bragging about is actually just United Healthcare using bullshit to get out of paying me what they owe me.
Hurdle score: this is hurdle #1 United Healthcare has erected between me and the money they owe me.
But wait, it says right there I can call ClearHealth to get this resolved! So I call them, leave a message, and wait a week for them to call me back. When they finally do, they’re like, “Duh, we don’t know what’s going on here, you’ll have to call your insurance company.” Hurdle #2, they told me to call people who, it turns out, can’t actually help me!
So I send the insurance company a message and wait several days for them to respond, and when they finally do, they tell me I have to fill out an appeal form. Hurdle #3, an appeal form, when they already have all the information they need to handle my appeal.
So I fill out the appeal form and send it back. A few days later they respond: nope, you can’t submit appeals online, you have to print them out and mail them on paper at your expense to this post office box in Minnesota. Hurdle #4: any insurance company which is still refusing to accept appeals online in the year 2025 is doing that for only one reason, to deter people from submitting appeals.
I just printed out the appeal form and mailed it in. I imagine Hurdle #5, still to come, is going to be either they won’t respond to the appeal within the time-frames required by law and their own policies, or they’ll try to claim they never received it, which is going to be a bit tricky for them since I used certified mail.
Fuck United Healthcare and fuck every person who works for them.
Fuck the entire for-profit healthcare system in the United States, and fuck everyone who perpetuates it.
UPDATE 1: In response to my complaint after being told that I had to submit my complaint via mail, I received the following today:
You are able to submit appeals online through your member portal as well if you’d like. You can do this by clicking the Claims and EOBs tab, then click Medical Claims. Select the name of the patient to navigate their claims, then select the claim you want to appeal. Once you click the claim link, you will go to a page that has an option to “Appeal this claim”. Please click that to begin your online appeal submission process.
Do we chalk it up to ignorance or malice that the previous support representative told me I had to submit it on paper? Either way, it’s a 🤡 show.
UPDATE 2: On July 25, over three weeks after I submitted my appeal, I received a response letter. The response was dated July 21 but the postmark on the envelope indicates it wasn’t mailed until July 21. So that’s Hurdle #6, delaying the handling of my appeal, probably intentionally, again hoping that if they make it arduous and slow enough I’ll give up. Let’s move on to Hurdle #7… The letter told me to call ClearHealth and said nothing else. I’ve already told them that I called ClearHealth and ClearHealth told me to call GEHA! I just sent the following back in response:
I am in receipt of your letter dated July 1, 2025, attached, telling me to call ClearHealth about this matter.
Incidentally, can you explain to me why, although the letter is dated July 1, according to the postmark on the envelope you did not mail it until July 21, nearly three weeks later? Did you delay the letter on purpose because you are trying to slow-walk the handling of my appeal in the hope that I will give up and you will not have to pay me the money you owe me? It sure looks that way!
As I already informed the GEHA representative with whom I spoke before filing this appeal, I did call ClearHealth. They told me they couldn’t help me and I had to call you.
I did not buy insurance from ClearHealth; I bought it from you. ClearHealth has no legal agreement with me; you do. My agreement is with you, and it’s your job, not mine, to get this problem resolved. If you need to deal with ClearHealth to resolve it, fine, you do that, but stop telling me to deal with them, especially when they’ve already told me to deal with you. It’s almost as if you and ClearHealth are giving me the runaround on purpose to make the appeal difficult in the hope that I will give up and you will not have to pay me the money you owe me!
Let me recap my complaint: either GEHA or ClearHealth came up with some arbitrary determination for what is a “reasonable” charge for therapy from a specialist psychiatrist treating a complicated condition. This determination is inconsistent with what these specialists typically charge and especially inconsistent with what they charge in the area I live in. As such, this determination was unreasonable and is what I am appealing.
Once GEHA or ClearHealth came up with their unreasonable determination, then according to the EOB they designated the rest of the charge for each therapy session as a “discount” that I was “not obligated to pay.” They have no authority to do this, since they do not have a contract with the out-of-network therapist in question and she is under no obligation to refund money to me just because the insurance company said a charge was “unreasonable.” That’s not how any of this works.
I want this “determination” reversed and I want to reimbursed for the rest of that money which I paid to the provider.
Furthermore, I want instructions from you for how to file an internal grievance with GEHA over how this has been handled.
Furthermore, I want instructions from you for how to file complaints with whatever government agency/agencies oversee your operations if this appeal is not promptly resolved in my favor.
Just to avoid all confusion, I am once again attaching the form signed by my daughter authorizing you to deal with me about this.
Thank you for your prompt attention to this matter.
