drowning in insurance crap for a year now

I am having a huge issue with UHC (PPO) and don’t know what my next steps should be. I will try to make this brief: A specific therapy was recommended for my son by his in-network pediatrician. The provider she suggested is OON. Our issues have been (1) a months-long prior approval process, which was unnecessary because the therapy was already listed as covered, even tho every other UHC person I spoke to told me that we needed prior approval; (2) a gap exception request to try to get them to treat the provider as in-network instead of OON; and (3) getting them to cover more than 20 visits in a calendar year. We started the therapy a couple months into all this mess bc we needed to get going on it, and all this is retroactive if it is approved.

Without going into all the mind-numbing details, this has been a mess at every step. I get different answers depending on who I talk to at UHC, such as being told that I myself can initiate the gap exception request, and then later being told that the pediatrician has to initiate it. I have been told that the gap exception was denied, and also that it was never initiated. I have even had them MIX UP the prior approval, gap exception, and therapy extension issues mid-conversation, where it’s clear they really don’t know what is going on. Basically, it is all obfuscation. No one does anything over there. I get these helpful-sounding people on the phone, who tell me what needs to happen, but then they are wrong or lying, and nothing changes. I was just on the phone with them for an hour and a half (until I hung up on them), only to be told that neither the pediatrician nor the therapy provider has ever submitted any medical documentation, which is a lie. The ped is about to tear her hair out over this. She has had long convos with UHS reps as well, and then when I try to follow up, UHC says, “hmm, no, I don’t see any notes about that.” She has submitted documents repeatedly, and they are just – what? Gone? Shredded? Burned? How many times is she supposed to submit all this stuff? I can’t keep asking her to do the same thing over and over.

The new fun thing, discovered today, is that my son no longer appears anywhere on our online UHC/Optum account. I logged in today to check the claims before I called, and neither of our kids are listed. Wtf? So now I can see neither the claims nor the EOBs. That’s convenient for UHC. Now I have even less information. The rep agreed with me that that is a problem.

So how do I escalate? It’s not that they have denied something I think they should approve, it’s that no one is apparently doing their job (or that they are actively lying). How do I make them keep the documents the doctor sends in? How do I make them take notes when they have a conversation with her? How do I make them stick to one story and be consistent? My husband is going to reach out to HR (insurance is thru his job), but what are some other avenues? The state Department of Insurance? Or do I threaten to sue them or something? I feel like this is beyond speaking to a UHC manager. I have 0 confidence that they are going to do what they are supposed to do, manager or no. Honestly, I would be happier and more confident in the process right now if they had said no to the gap exception and to more than 20 visits. It would be an answer. But we are stuck in the process, and they apparently want to keep it that way. It’s been A YEAR. wtaf???