I had a detached retina then had to have cataract surgery. My policy says glasses are "covered" after eye surgery. I called UMR about purchasing glasses at Walmart. I was told to purchase the glasses then send in the receipt and I would get payment. After purchasing the glasses, I sent in everything. I received a billing from UMR saying the glasses were not covered because it was from a "routine eye exam".
I called and explained the situation to two different people and was told that a mistake had been made on their part and that they would reimburse me for the glasses (talked to Gina I believe). No money. Called again and talked to Josh. After 25 minutes on the phone, he too reassured me that the glasses were covered and that I would be receiving reimbursement. He said he would use his lunchtime to complete this and would call me when it was settled. Great guy - actually went out of his way to help. He left a message on my phone that afternoon that he had it all taken care of and that I would be receiving reimbursement. No money.
Yesterday talked to Sue in Claims. She now says the cost of glasses was applied to my deductible. Her words, "When the policy says it is covered, it means that it is applied to your deductible". What?? I talked to three people before this and never was that mentioned. Then I noticed I had reached my deductible and pointed this out to her. She then told me that Walmart is not in the network of providers so I could not get reimbursed. When I told her that I called to check on this early in the game, she ignored my request to review earlier notes on my account.
When I asked to speak to someone else, Sue told me she sat next to the person who determined the claim and that she already checked with him and she has it right. To add more to the frustration, I asked Sue to direct me to a survey I had agreed to take at the beginning of the call, she said she would connect me then promptly hung up. I was never disrespectful or rude during this entire conversation. The prompt also says that calls can be recorded. I would like them to use those calls as proof of the poor service I am receiving!
IOWA -- I can't download my Benefit plan document pdfs from their website. All that downloads is the pdf icon- not the actual pdfs. I can't double-click them to view online either. UMR Customer Service is horrible when you call them by phone. You are put on hold for a minimum of 15-20 minutes a shot until you give up and decide to try an hour later - then it happens again. Also, the operators can't seem to transfer you to the correct dept, as you repeatedly wait, get someone to answer briefly and apologize that this is not the correct dept and they have to transfer you again and again. Honestly, this is worse than a government agency.
HOUSTON, TEXAS -- I've had this insurance for about 3 years. First year I caught the flu I went to the doctor. I unexpectedly had to pay $100 OUT OF POCKET at an IN NETWORK Dr's office! Surely there was some mistake so I called and had the worst customer service ever. Two years later I am having to see a podiatrist and I made sure to call insurance to be prepared of the expenses. Found out my deductible is $5,000! I'd have to basically spend 500 times in a year to be able to use receive any benefits!! Hate to think I've literally thrown thousands down the drain for a horrible insurance company right into their pockets!
UTAH -- My child was in an accident that left her body covered in burns. I took her to the only place in my state that treats burns such as hers and was informed they are out of network. EVERY TIME I called and asked not one employee was able to tell me of an in network provider who could treat my child's burns. They are great as long as you weren't in a car crash, house fire, accident with hot liquids anything that can burn you because at that point it just sucks to be you and they won't cover it.
Well called UMR health insurance company today. First they tried to tell me, again, that records were requested and they were waiting. I told them that what they said 6 weeks ago until they checked another "file" and found them misfiled! Now they say that those records came 6 weeks ago but it's still in review which is unusual since it's been 6 weeks in review and 19 weeks from the original claim. So now they will put a “rush” on the review. UMR is evil.
MILWAUKEE, WEST VIRGINIA -- Tried to phone them. They wanted PIN number, which we don't have. Call was automatically transferred to "Operator", whose mailbox was full and we couldn't leave a message. How in God's green earth can you contact these people if you don't have a computer. I have found that all of these 3rd party billing companies are very poorly operated.
SOUTH JERSEY, NEW JERSEY -- Hard to find doctors that take it. People on the phone are unsure what will be covered and what my out of pocket would be. Example: x-ray for my back. Turns out it was covered %100 just with a copay but that's not what they said when I called twice and got 2 diff answers. No one said it would be covered 100%. Could have saved me some worry but at least I didn't pay. Also, doctor offices have tried to call them about copays while I am there but can't get through.
PHILADELPHIA, PENNSYLVANIA -- UMR automatically rejects claims, stating you already have primary coverage elsewhere. They know this to be false, as who would pay 2 health care premiums. It is their default reaction, in order to hold on to their money longer. This type of behavior should be illegal. I now have to take time out of my day and call UMR and swear on a recorded line, I have no other primary insurance coverage. I need to do this every time I take one of my kids or myself to a doctor's appointment.
WAUSAU, WISCONSIN -- In the Summer of 2015, when I was 56 years old, I spoke with my personal provider during a scheduled physical about some difficult and painful varicose veins I had in my right leg which were preventing me from exercising, having the ability to regularly sleep sufficiently to feel well rested, and which significantly contributed to an excessive weight gain. I was referred to a local surgeon by my provider and I verified that he was covered by my health insurance (UMR) to provide me with services with a UMR Insurance Representative. I have a family history of severe varicose veins along with a familial history of vascular and heart disease.
In October 2008 I sustained a myocardial infarction which resulted in surgery, hospitalization, and extensive cardiac rehabilitation. In 2010 I had similar veins in my left leg which were ablated through a radiofrequency ablation through the same surgeons office by another surgeon at the same Outpatient surgery center and called UMR and received no difficulty in having the procedure costs paid for. The employer and insurance through that employer that I had during the first surgery was/is the same as for the second surgery.
I informed the surgeon as I had the primary provider that I was intending to retire at the end of 2015 and that I wanted to take care of any significant medical issues prior to retiring. The surgeon agreed that this was a wise way to proceed and he informed me that 3 visits with him for visual assessment and a vascular ultrasound and photographs were necessary to meet the standards of the insurance company. On October 24th after the 3 visits with the surgeon and the vascular ultrasound and photographs were completed, the surgeon's office submitted the information to UMR Insurance for Pre-determination of need and payment of benefits.
The surgeon's office received a letter indicating that there was no need for this and that the procedure was covered under my employer's insurance plan with the surgeon and the surgery center I intended to use. Approximately a week and a half prior to the intended surgery date (November 23rd, 2015) I contacted UMR Insurance and spoke with a representative. During the contact I made it very clear that if the surgery wasn't going to be covered by UMR insurance that I would have to postpone it until such time that insurance would cover it because I did not have the available funds to pay for the procedure.
I repeated that I did not have the available funds to cover the costs of the procedure several times and each time was told not to worry. The representative assured me that the procedure was a covered procedure by my plan and the only question she had was to ask me if the surgery was going to be done in a hospital or in an outpatient surgery center. When I told her an outpatient surgery center she again reassured me that the procedure, the provider, and the intended outpatient surgical center were part of my plan coverage (indicating that it would be covered) and that I should go forward with my tentative plans for the surgery.
On November 24th (the day after the surgery was completed) a letter was generated by UMR insurance which I received the following Friday which was the day after Thanksgiving 2015. The letter indicated that the size of the vein which ablated was not 5.5mm at the saphenofemoral junction (I later found out through the surgeon's insurance liaison that the size was over 5.3 at that junction and within 2 inches below the junction it was 5.7mm) and as such that the procedure and its costs would not be covered to the cost of $16,520.
The surgeon's liaison also indicated that neither she nor the surgeon were aware of this measurement requirement at the point where it was identified. I have submitted the above information to UMR insurance along with a request for an appeal and have made numerous telephone calls to the UMR Representatives to be told that it is being reviewed and that the representative would get back to me which they never did. I have on more than one occasion requested that I be sent a written response to my appeal and I have only received an explanation of benefits notice denying my claim stating that it was not a covered benefit under my plan.
My last telephone call to UMR last week (Feb 26th, 2016) had me talking to a UMR representative, after waiting on the phone for 10 minutes who then hung up on me after she said she was going to transfer my call to another young lady who I had talked to 1 1/2 weeks earlier who said she would call me back in 2 days and in 1 1/2 weeks did not call back. The representative then later called me back threatening that she wouldn't be able to help me if I hung up on her again. That representative stated that unless I submitted another appeal there was nothing they could do.
I informed her that in January 2016 I had sent in an appeal. She stated that because my initial appeal was received while the procedure and benefits were being reviewed another appeal would need to be submitted. I have sent this in as requested on February 27th, 2016.
To this date the insurance, although they have refused the claims for this procedure have covered/paid approximately $800 and negotiated a $2000 reduction in the surgeon's costs and paid a little more than $590 to the outpatient surgery center and negotiated a $3452 reduction leaving me with $8168.00 to pay out of my limited monthly retirement pension. This process has caused me, my family, and my surgeon more than a little frustration.
BETTENDORF, IOWA -- I called the company before I scheduled my surgery, that my DR. said that I needed and they said I was approved, so we scheduled it. Then, the "nurse" that works for them denied my claim and said that I could do other things before this. I am sorry, but if the DR. said that you had precancerous cells in your body you would want them out. How can an insurance company deny someone a surgery that is to get cancer out of the body? Then, when I called her to ask questions, she never wanted to call me back. Very disappointed and will be looking for a new insurance company that cares about the customers.