I have a Unicare PPO plan in Illinois with a high deductible ($1,500 individual, $3,000 family). They have a list of doctors and facilities that are on their plan. But even when you go to a facility on their list, they won't pay if it is "billed wrong." They say they won't pay for anything billed as an outpatient visit, unless the high deductible is already paid. My husband went to an in-network urgent care center (not the ER, which saved money) for a corneal ulcer, and Unicare denied payment because it was billed as an outpatient visit. The CSR I talked to said that we should have called ahead to find out how the facility bills.
So now we have to make sure it's a covered condition, and that the provider is in-network, and then we have to call the specific provider up and grill them about their billing practices to find out if it will be covered. This refusal to pay depending on the billing of the procedure seems like a way for Unicare to weasel out of paying bills to me. It seems to me if they were on the up-and-up, they would list facilities that are in-network and adhere to Unicare's arbitrary billing requirements, so that we could choose where to go. I don't see how it makes sense for each of Unicare's insured people to call each facility to find this out, or more likely, find out after getting care that it isn't covered. Have you heard of this kind of denial based on how the facility bills visits?
