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.
