March 4, 2008 Feature

Insurer to Reimburse Mismanaged Claims

Speech-language pathologists and audiologists are eligible for reimbursements for claims submitted to and erroneously processed by UnitedHealthcare Insurance Company's (UHC) state plans under a multimillion-dollar settlement agreement with most state's insurance regulators.

The agreement follows an investigation by state insurance regulators initiated in 2004—through the National Association of Insurance Commissioners—as to whether UHC and 25 of its affiliated state health plans had fully reimbursed providers and plan beneficiaries to the extent that they were entitled.

The agreement affects only commercial health care insurers who operate on UHC's two core claim processing systems (UNET and Cosmos), and does not apply to Medicare, Medicaid, or self-insured businesses.

Although UHC did not admit to violating any laws, it did agree to pay an assessment to each of the 36 regulatory bodies of states and the District of Columbia that were parties to the agreement (as of Aug. 31, 2007) to settle regulatory findings and to reimburse states for the cost of analyzing UHC's market conduct. UHC must also reimburse providers and plan beneficiaries for erroneously processed claims.

Providers' and beneficiaries' claims that were denied or partially paid due to administrative errors—including coverage determinations—are eligible for reimbursement. If UHC's claim review results in approved, retroactive coverage, the beneficiary's provider will then be entitled to reimbursement for the services rendered. UHC is obligated to reach out to providers with high-volume complaints or issues and resolve them.

This settlement could result in corrective payments (plus interest, as allowed by state law) to providers who participated in a UHC health plan and rendered services dating back to 2004. It appears that providers do not have to initiate action to receive any funds due under this agreement, as UHC is required to investigate claims and make payments under the oversight of state insurance regulators. The agreement is in effect from Aug. 27, 2007, through Dec. 31, 2010.

State regulators have signed on to this agreement in Alabama, Alaska, Arkansas, California, Connecticut, District of Columbia, Florida, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, West Virginia, and Wyoming. Both the regulator and the health care plan in a given state must be parties to the agreement for claims in that state to be subject to restitution.

Angela Foehl, director of private plans advocacy, can be reached at

cite as: Foehl, A. (2008, March 04). Insurer to Reimburse Mismanaged Claims. The ASHA Leader.


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