United Healthcare

This post was created for all United Healthcare patient seen at Indiana Sinus Centers. In 2022, across the nation, United Healthcare’s official policy recognizes Balloon Sinuplasty as a covered service. Unfortunately they have been intermittently denying Prior Authorizations that DO MEET their published criteria for coverage.

Here is United Healthcare’s Policy for Coverage and what steps you can take if United Healthcare does not honor the coverage policies contained in your health insurance contract.

2022/2023 United Healthcare Policy on Balloon Sinuplasty

Balloon sinus ostial dilation is proven and medically necessary for the treatment of Chronic Rhinosinusitis which has all of the following:

• Lasted longer than 12 weeks
• Persistence of symptoms despite administration of antibiotic therapy if bacterial infection is suspected
• Persistence of symptoms despite administration of intranasal corticosteroids
• Persistence of symptoms despite administration of nasal lavage
• Confirmation on a computed tomography (CT) scan for each sinus to be dilated
• Sinonasal symptoms such as pain, pressure, or drainage are present on the same side as CT scan findings of rhinosinusitis
• The balloon sinus ostial dilation limited to the frontal, maxillary, or sphenoid sinuses
• The balloon sinus ostial dilation performed as either a stand-alone procedure or part of Functional Endoscopic Sinus Surgery (FESS)

Link to Official Policy Statements

National Lawsuits Against United Healthcare are $500 Million

Panel Orders UnitedHealthcare to pay $10.8M for Alleged Underpayments

This lawsuit is one of nine cases throughout the country that TeamHealth has brought against United for alleged underpayments. The other eight cases are still ongoing. 

“United persists in exploiting vulnerable patients and refuses to adequately pay providers, despite having faced sanctions, jury awards, and settlement payments of some half a billion dollars,” said Dr. Jay Mesrobian, TeamHealth National Medical Director and Chief Clinical Officer.

According to the news release, the panel found that UnitedHealthcare (UHC) had paid TeamHealth physicians 30% of what they were owed as “fair payment” for their care.

“This judgment reflects United’s ongoing, extensive wrongdoing that puts their billions of dollars in record profits ahead of patients’ well-being and the U.S. healthcare system. We will continue to fight United until they change course and start fairly compensating providers,” the company said in a news release.

The contentious legal battle between the two companies began with a separate case in which a Las Vegas jury in late 2021 awarded $60 million to TeamHealth. That award included punitive damages on top of millions in compensatory damages for UHC’s underpayments on thousands of claims for treatment.

Link to Article

Patients Have Rights – What you can do if your claim is denied with United Healthcare in Indiana

The physicians and staff at Indiana Sinus Centers believe that if you are sick and you have insurance that covers treatment, your insurance plan should honor the contract you have with them.

If you have United Healthcare and we have attempted to contact them for treatment and they have denied your case, please understand:

• We are acting on your behalf spending hours on the phone with United Healthcare arguing with reviewers and we are working as your ADVOCATE in your healthcare journey
• If you call them they will tell you how easy the process is and also tell you that we need to do something that we have already done and then your case will be approved
• United Healthcare is LYING TO YOU if they say this and ARE NOT ACTING IN YOUR BEST INTEREST OR AS YOUR ADVOCATE contrary to their advertising

If this happens with your submission we would suggest that you do two things immediately as this may help them eventually approve your procedure as a covered service:

• FIRST – Call the customer service number on the back of your card and complain that they are not following their coverage guidelines for Balloon Sinus Ostial Dilation (you need to use this term as your call will be recorded and reviewed by the IDOI)
• SECOND – File a free complaint with the Indiana Department of Insurance (IDOI). This is a free service where the IDOI will review your case and United Healthcare’s Policy and potentially help your case get approved
  • LINK TO FILE A COMPLAINT (this link will note work on mobile and requires you to login with and email and create a password)
  • Main IDOI website for filing complaints is HERE (Scroll down to File a Consumer Complaint – Online Form)
  • Cut and paste this text into your complaint: “I was seen and evaluated for treatment of chronic sinusitis. I met criteria for coverage of Balloon Sinus Ostial Dilation per United Healthcare’s published policy but they are not approving my Prior Authorization or recognizing it as a Covered Service in contradiction to my insurance contract. Please investigate this further. Thank you.”

Please be respectful in all interactions you have with the IDOI and with the Staff and Physicians at Indiana Sinus Centers. We are your only advocates in these unfortunate circumstances.

We look forward to partnering with you in good health and sincerely hope this information helps you both understand this unfortunate situation with United Healthcare and also get the care you need to recapture the quality of life you deserve.

Sincerely

The Healthcare Providers and Staff at Indiana Sinus Centers