Medical Underwriting for suppliments/Medigap

[CBtoo]

I went to change from UHC supplement G+ to G as that would save me about $70/mo. Getting actual useful information out of the medical underwriting people is like pulling teeth and then some. 

I failed - not because I should have but because of mistakes in my medical record (eg coding errors and in two cases people listing in my visit notes issues I neither saw them for nor have). As a result of that in care everywhere (where EPIC/MyChart parks your diagnoses) I have wrong things (that are causing me to fail - although it took 3 phone calls to finally get a list). And some wrong codes have been listed with billing me.

I have corrected all but 2 things on that list and can't figure out how to do those last two. In one case I called the head of billing and she had codes corrected in their system and then re-submitted the bills with the corrected codes.

In the other two cases I had one person fix his visit notes but can't get him to report this to billing so they can fix the codes there and resubmit the bill to fix mistakes. The other one I have had to file a patient advocacy complaint to deal with it (not yet resolved).

To make this a bigger mess with medicare EOB's they only show some of the codes and calling medicare won't get you the rest of them (It was from them I even found out there are more codes than what we can see). You have to get them from the system that filed the claim. Apparently UHC can see both sets of codes although I don't know the context in which they see them.

So does anyone know if UHC looks at just the "uncorrected" claims they have already paid for me (thus I have to somehow force two claims to be resubmitted with codes removed)?  Or do they go into the 'system' where you get care and see what is there and the current codes present? I can't get UHC to tell me this one way or the other despite repeated calls. How the heck we can fix things to their satisfaction is a puzzle to me if they won't even volunteer or tell you the entire list of issues. I do not have ESP.

Does anyone know how, exactly, this works? I have spent nearly all of my appeal time messing with this Of course I can just reapply - which is easier than appealing (and cheaper as then I don't have to pay for a ton of medical records to be sent to them - but why bother re-applying if things aren't fixed where they go looking?

Thanks!

[CBtoo]

I went to change from UHC supplement G+ to G as that would save me about $70/mo. Getting actual useful information out of the medical underwriting people is like pulling teeth and then some. 

I failed - not because I should have but because of mistakes in my medical record (eg coding errors and in two cases people listing in my visit notes issues I neither saw them for nor have). As a result of that in care everywhere (where EPIC/MyChart parks your diagnoses) I have wrong things (that are causing me to fail - although it took 3 phone calls to finally get a list). And some wrong codes have been listed with billing me.

I have corrected all but 2 things on that list and can't figure out how to do those last two. In one case I called the head of billing and she had codes corrected in their system and then re-submitted the bills with the corrected codes.

In the other two cases I had one person fix his visit notes but can't get him to report this to billing so they can fix the codes there and resubmit the bill to fix mistakes. The other one I have had to file a patient advocacy complaint to deal with it (not yet resolved).

To make this a bigger mess with medicare EOB's they only show some of the codes and calling medicare won't get you the rest of them (It was from them I even found out there are more codes than what we can see). You have to get them from the system that filed the claim. Apparently UHC can see both sets of codes although I don't know the context in which they see them.

So does anyone know if UHC looks at just the "uncorrected" claims they have already paid for me (thus I have to somehow force two claims to be resubmitted with codes removed)?  Or do they go into the 'system' where you get care and see what is there and the current codes present? I can't get UHC to tell me this one way or the other despite repeated calls. How the heck we can fix things to their satisfaction is a puzzle to me if they won't even volunteer or tell you the entire list of issues. I do not have ESP.

Does anyone know how, exactly, this works? I have spent nearly all of my appeal time messing with this Of course I can just reapply - which is easier than appealing (and cheaper as then I don't have to pay for a ton of medical records to be sent to them - but why bother re-applying if things aren't fixed where they go looking?

Thanks!

[GailL1]

@CBtoo 

What a mess - are you having to change your Medicare file so that the change flows from them to the Medigap plan?  Seems that would be the only way it would work and even then, I still don’t know if the Medigap insurer would take that into consideration.  I saw a list somewhere the other day on all the illnesses / treatments that would potentially cause underwriting to be performed - seem it was a rather  severe list - but lots of chronic illnesses that can lead to further problems down the road. 

I am pretty sure that since Medigap is not really health insurance - it is gap insurance that there are not any Medigap rules that are gonna force them to change you even if you got them all corrected.  Medigap insurers are not legislated as to their call on when they have to underwrite or NOT.  Some states will also allow them to disqualify a certain preexisting for a specific time period on any new policy change.  The only time when they cannot do this under Federal law is your initial enrollment. 

If you are not in a state that has some extended guaranteed issue period - certain time or continuous - then the only other way is to find out if ANY of the Medigap insurers in you area is conducting a special Medigap enrollment. They might be more lenient in letting you come onboard with their company.  Only an independent broker would know of any such current offers in your state.  So have you considered another Medigap insurer?  

Many Medigap insurers are being faced with high risk loss ratios and are rising their premiums for 2026. It seems that AARP UHC is one of these.

I wish I could be more hopeful for you - especially since you are just dropping the extra coverage but keeping the same plan - BTW, they might do it but raise the new premium to the same amount you are paying now.  They have a lot of leeway. 

[TRL1111]

---

@GailL1 wrote:

If you are not in a state that has some extended guaranteed issue period - certain time or continuous - then the only other way is to find out if ANY of the Medigap insurers in you area is conducting a special Medigap enrollment. They might be more lenient in letting you come onboard with their company.  Only an independent broker would know of any such current offers in your state.  So have you considered another Medigap insurer?  

Are these common?  I know about the SEP for disasters, which can be used by unscrupulous agents to have people switch from one Advantage plan to another outside open enrollment.  But I'm pretty sure they don't apply to supplements.

And in thinking about it, why would a supplement offer open enrollment when they're not required to?  Seems to me they would just do their usual underwriting thing and maybe be more lenient if they wanted to add more people, but not open the door to everyone with a guaranteed-issue period.

And like you, I wonder why Carolyn is looking only at AARP/UHC.  With the $70 reduction in premium, will it then be the lowest-priced choice?  If not, maybe look at other carriers.  They can have differing underwriting standards, even though from what Carolyn says, underwriting would not be an issue if the medical records were correct, and that's the core problem--getting the medical records corrected.  If I understand the situation correctly, she shouldn't have to be looking for a company with lower underwriting requirements.

[GailL1]

@TRL1111 wrote:  . . . . But I'm pretty sure they don't apply to supplements.

And in thinking about it, why would a supplement offer open enrollment when they're not required to?  Seems to me they would just do their usual underwriting thing and maybe be more lenient if they wanted to add more people, but not open the door to everyone with a guaranteed-issue period.

==========================

This has been in the back of my mind for a while but since I finally found an example in the state of IL - I thought I would let you know about it. 

ILLINOIS Dept of Aging.gov - 2025 Medicare Choices  

See specifically Page 12

[copy / paste]    Specific to the State of IL.  

Guaranteed Issue Policies from a Guaranteed Issue Company

For persons aged 65 or older and NOT in their Open Enrollment Period or any Special Enrollment Periods there is still an option to get a Supplemental plan. In Illinois, we have one Medicare Supplement insurer that offers policies to anyone over the age of 65 in ANY health

condition, throughout the year at the same premium rate as anyone in the same policy class. That company is Blue Cross Blue Shield of Illinois. NOTE: BC/BS also has some plans with underwriting.

So you see, this is different than underwriting - but as to which one might cost more -the underwritten one or the one from the GI Company -  IDK.  

I don’t think this is the only state where BCBS does this sort of things - sometimes it is just something they offer from time to time, here and there.  

[CBtoo]

Addressing your tier two pricing comment. For example, stage 3 kidney disease you will pass but you will pay more (eg tier 2 rates) for the new coverage (which in the case of UHC makes it more expensive than paying for the extras - at least they told me they won't push you into tier 2 of the plan you already have if you don't switch. Stage 2 you are good to go and have tier one pricing. 

I wouldn't have had any of these issues if my providers weren't so sloppy and/or someone wasn't upcoding. Fixing this kind of stuff is a nightmare as no one is all that willing to tell you how and it takes a lot of people to follow through with what needs done. 

[CBtoo]

It is UHC and June 2023 they opened a new G in our state (and some others) that don't include the "Free" extras (gym, etc.) and it is enough cheaper it would be worth bailing from the one that offers all that not free crap (or both G's they'd be close to the same price and they aren't - we are paying for them but they are calling them free), BUT in order to bail I have to pass medical underwriting because I have no GI available for any reason and don't live in a you can change once a year state. That is true for anyone who wants to change their supp. 

So I called UHC yet again and yet again talked to someone in underwriting (I have the direct line as I saved it and fortunately that is not outsourced overseas). They gave me new information and added some more visit dates and a new diagnosis that isn't true that I will need to fix. Makes me want to call them daily to see what else is found. Sigh.

So this is what this guy told me - for each appointment that they have on record with any of a list of diagnoses and codes they flag the place I saw the doctor at needs to file a corrected insurance bill to medicare who then should send it on to my UHC medigap G. Once UHC has processed it then those appointments are removed from the list of what will fail me.

Some crap has a 5 year look back and some has a 2 year look back. 

This guy's initial response was for me to call/look at my EOB to see what is there. I told him they told me that the last couple of times and were unable to help me; that since they (underwriting) knows what they look at please go look and tell me the dates of the apts that would cause me to fail based on what they fail you for. He gave me additional appointments and one more condition I don't have than I was given the last two times I called (and the last time I called I was given more than the first time). 

So now I need to fix some of that crap. Fortunately two of the apts run past their look back time limits in Aug and Oct and one of those doctors is a class A jerk who likely will refuse to help, so I am going to wait until after those two apts roll over and out of the look back. Meanwhile I will try to get the rest of them fixed and then apply again (well I will call first to make sure all of the revised insurance- medicare and G - claims have been submitted and work on them completed). But before I apply again I will call to make sure all of those things have been removed and medical underwriting won't be flagging anything else I don't know about yet. What a PITA. 

In the meantime I will be paying over $1000 or more than I could be paying were I not faced with all these errors. I am reasonably sure that some of them were deliberate upcoding based on what some of them are.

Anyway here is a summary for what one needs to do to get rid of errors in your medical records for supps and thus being able to pass medical underwriting

1) Find every single visit where someone used the wrong code. Since we don't have access to all of that on our medicare EOB's  it will require either having a cooperative billing office or having to pry it out of underwriting at UHC.

2) Get each and every visit recoded and then resubmitted because they are fixing a mistake. That has to go through the entire process before it will be considered fixed. How do you know it goes though? I found asking underwriting and giving them the dates they gave me before, that I got fixed, if it still shows up. So far one condition has been fixed and will no longer fail me.

3) Find out the look back time frame - most commonly with UHC they are 2 years or 5 years (some companies have 3 years). It may be easier to wait until some of those apts that need fixed "age out" than deal with fixing it depending on the provider who may or may not be willing to do what needs to be done and their billing office.

4) Once all that clears it is easier to re-apply than appeal as you have to pay for a zillion medical records (they are not free to send to an insurance company) for how every many years the look back is for each condition plus ALL your PCP records for the look back time period. 

I wish there was a way to get out of my providers how much extra I am paying because failing medical underwriting due to this is their fault due to their mistakes and not mine. 

Do NOT expect any of your providers to have a clue what they need to do nor the billing office of your provider. I had to educate them too.