I live in Birch Bay, WA and UnitedHealthcare is my insurance. Last year, I needed a treatment, but there was no UHC network provider in the area. I contacted a local provider, who then negotiated an agreement directly with UHC detailing the billing code, duration and cost to treat me. Upon completion of the treatment, the provider billed UHC as per their agreement. After 2 months the provider called me for payment (he did not want to deal with UHC, being aware of their reputation in the Bellingham area). I looked online and saw the status was 'pending' then called. They said that the note in the file said they were waiting for a copy of the providers medical license, since he was out of network (though approved signatory to their single patient agreement--but hey OK). Provider said he had received a letter and faxed UHC a copy of his license over a month ago. Here is a brief synopsis of the bizarre communications between me and UHC over the 5 months to reach payment.

I know enterprise software very well, including call center tracking. I worked for a company that is now one of Oracle's ERP offerings. FYI, there is always a 10-14 day wait between all communications for any UHC action to take place and be 'processed'.

-- UHC said license had not been received, so refaxed and waited for scanning dept. to attach it to my claim.

-- UHC customer service rep said he still doesn't see it (scanned and attached to my file), so faxed again waited.

-- rep says still not received, but oh wait!!, there it is. So finally it is 'in process' (that will be a 10 -14 day wait for processig)

--still no payment, rep doesn't know why, but will send a 'priority email' to claims, since he can't actually speak to that group and wait

--still no payment, rep guesses the billing code looks incorrect, faxed claim with code change (but originally correct per agreement) and wait

--still no payment, rep will send another 'priority' email to claims (and wait another 10-14 days)

--still no payment, rep says note says claims waiting for coy of license (huh??) re-faxed months ago and had actually been seen by a different rep ( I supplied call number for his reference, but he should have all my communications on this claim on the screen) Oh yeah! there's the little rascal. Rep will send another 'priority email' to claims letting them know its here. (Duh, these are electronic files, and claims can't see what he sees?)

--still no payment, I told rep to pull up by claim number, and he couldn't see the scanned license. I said pull up by my member ID number. Sure enough, there was my single claim and the scan of the license. Hmmm. Bump to supervisor.

--still no payment, sections of the above do loop repeated several times. I finally called the the agreement approval group and had to pretend I needed a new approval to even be connected. I explained that the claim was exactly as per agreement, but the scan of the license was attached to my file at the account level and not to the claim number -- and the magic software keystrokes making that electronic connection was beyond the expertise of customer service, customer service management and claims.

You know how complicated and sophisticated those computers systems are, which I guess makes those expensive CEOs worth every penny for their enormous contribution to efficiency and employee training.

Actually, companies are taking health care reform seriously because of the penalties involved. My company is a consulting firm and health care consulting is what we do (not my location, but most of our other locations). Lots has to change, both with health care reform and mental health parity, and companies are trying to change their benefits to be compliant. Maybe it's mostly with mental health parity, but I read or skim the constant updates the company puts out about things like increasing the age of insured kids, although I didn't think it was 26. i guess I should pay more attention. There's so much that's unknown still.