CMA recently received a number of calls from physicians whose claims for services provided to patients with “point of service” (POS) plans were being improperly denied by PacifiCare/United Healthcare (PC/UHC). As you know, POS plans allow patients the freedom to pay a higher copays and/or deductible if they want to see specialists outside their medical groups/IPAs. The insurer had been denying such claims, saying that the responsibility for payment lay with the patients’ medical groups/IPAs. Claims submitted to the patients’ medical groups/IPAs were also denied, because the patient went “out of network.”

CMA brought this problem to the attention of PC/UHC’s liaison team, and it was determined that a system glitch was causing the denials. As of March 5, the glitch has been fixed and PC/UHC is working to identify all improperly denied claims. These claims will be reprocessed (with interest, when appropriate).

It is not yet clear how long it will take for the claims to be identified and reprocessed. More details will be published in CMA Alert when they become available.

Contact: CMA’s reimbursement help line, 888/401-5911.