Complaints

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• Initial Complaint

  Date:06/05/2024

  Type:Billing Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  ************** office took money from my mother-in-law & refuses to reimburse her for out of pocket charges for a service that her insurance pays for.*** spent hours on the phone with the insurance ** trying to get this resolved.The ************ has explained to *********** that she needs to file ins.The office is not up to date on filing laws & use expired ******** forms that are not updated or explained to patients for the use of the forms. The insurance ** **ntacted *********** & asked her to file claims for 7/31/23 & 2/1/24 & insurance is now processing the 2/1/24 claim. as of last Friday, 5/24/24, the office told me they were instructed to not speak with us about the claims or reimbursement anymore & to do what I need to, to try & get reimbursed from *********** who was paid twice once by my mother-in-law & again by the insurance ** for the 2/1/24 visit. We dont understand why *********** charged my mother-in-law $75 for that 2/1 visit but only billed insurance $66. Since Ins is processing the 2/1 visit *********** now owes my mother-in-law $75.*********** also owes around $1500 to her for this same procedure **de that is payable by insurance for visits from 2016 to date.When I called the office & questioned their billing practices & why they didnt file ins, *********** sent my mother-in-law a letter dismissing her from her practice.There has been a grievance filed by us, the insurance ** & a **mplaint to ******************* of ********** now have to try & get my mother-in-law reimbursed.I have a billing statement from *********** along with ins documentation showing the services provided are **vered & payable, the out of pocket pymts made by my Mother-in-law & that the dates were never filed to her insurance.United Healthcare Advantage said that *********** is in network & is required by law to file or provide the info for us to file.My mother-in-law also has Tricare4Life as her se**ndary payer so she would owe nothing..This practice needs audited & as Were still fighting the 7/31 claim. Help!

  

  Business Response

  Date: 06/05/2024

  It is a HIPAA violation to discuss medical and billing information without the patients written permission in advance of treatment..  We were not given permission nor a ***** of ******** for any family members to discuss her treatments. 

  The patient *********************** has been a patient here since 2016 and she has been paying out of pocket for noncovered service on a regularly. She was aware the services offered were noncovered by insurance and was very satisfied with her treatment .  When she moved in with her family all of a sudden the family was dissatisfied with her treatment and insisted on not paying for noncovered services!

  We filed with her insurance as the family requested but have not heard back from the insurance company.

  Customer Answer

  Date: 06/07/2024

   
  Complaint: 21796928
  
  I am rejecting this response because:

  The "non-covered" charges this office is referring to are actually "covered services" which you will find proof of in the previous attachments that were sent.  If it is a HIPPA violation to discuss patient information (and it is) you will find in the attachments where I conversed with *******************, **************** Billing and Insurance Specialist via email on 2/20/24 along with a phone conversation with *** on 4/26/24 which resulted in *** sending me a patient ledger regarding my mother-in-law's account which shows the billing discrepancies. For your convenience, I've attached those copies again. I also placed a call to the office and asked if the practice had a patient portal that their patients could use to retrieve their medical records and ******************* told me that they did and even proceeded to instruct me on how to set it up in order to retrieve my mother-in-law's medical records (that were also attached previously).  Please be aware that **************** office tried to bill my mother-in-law $42.00 for her records that we got free with no mention of the patient portal ever to my mother-in-law or when ************ sent the email on 2/20/24 stating that she had sent my mother-in-law a 30-day termination letter (this was also in the previous attachment) and felt that my mother-in-law should seek alternative care.  The problem I have with this is that ************ is an in-network provider who accepts assignment and is shown on UnitedHealthcare's website, which I attached a copy of in my first correspondence.  It is not very professional for a physician to terminate treatment on a patient just because we had questions about my mother-in-law's billing discrepancies. To me, this insinuates that the office knew or now knows that what they are doing in wrong because *** was helpful and sent me all of the requested items needed in the beginning until the office realized that we were seeking reimbursement from ************. After that, the office would not answer my phone calls because they were able to recognize my cell number, so I had to call from different numbers just to reach them. After UnitedHealthcare informed *** that they were to bill insurance, I was told last Friday, 5/31/24 by *** that "She has instructions to no longer answer any questions or speak with me/us about the billing or account and that I could "do whatever I felt I needed to do" to try and seek or get reimbursed when I told her I would consult a lawyer if necessary if I could not get this resolved any other way.  Apparently, they are not aware, then maybe again they are that insurance will generally pay for services for patients who have documented medical necessity and claims filed with the necessary ICD-10 codes and correct modifiers that can be easily looked up online, so this does not continue to happen as I am almost sure this is a common mistake being made in **************** office.  I'm sure there are patients just like my mother-in-law who have documented medical necessity in their medical records in **************** office that provide the necessary information for claims to possibly get paid EVEN if insurance doesn't normally cover it.  But ************ seems to think that her office policy she implemented and sent to me will stand in court (a copy of this was in the previous attachments) even if it goes against what the current insurance carrier is requesting her to do.  This was also told to *** by UnitedHealthcare.  

  I agree with one statement that the office made in their rebuttal, it is correct that my mother-in-law was a patient since 2016, however, as far as her satisfaction with their care, that changed once she realized that they were stealing from her by taking over $915.00 from her.  My mother-in-law trusted her care to this physician and **************** office staff, and it sickens me to know that she lives on a fixed income, and they were taking advantage of her and possibly other elderly patients that do not know the ins and outs of how insurance works. My mother-in-law did not understand what the Advanced Beneficiary Form (***) she signed was for when I showed it to her, and I don't understand how the office can even think that the form they are using as proper documentation is legal as it has not been filled out by my mother-in-law giving her informed decision about her care to **************** office.  I worked in the medical field for years and did billing, and this is called using a "blanket *** form" which is not permitted by ******** as they require these forms to be updated yearly, or when the form becomes obsolete and is replaced with a newer version, a different type of care is performed or when fees change such as they did from $60.00 to $75.00.  This form they are using is obsolete and has been for a few years now.  At that time, the newest version of the form is***d by ******** which can be found on their website should have been completed by my mother-in-law showing that she acknowledged the fee increase. I'm attaching the blank *** form that is dated 2016 that was sent to me by *******************, the Billing & Insurance Specialist for **************** office. If you notice on the *** form for section "G" it states, "Check only one box.  We cannot choose a box for you."  This should have been addressed and asked that my mother-in-law fill out the form and if she had any questions.  I would like to clarify that when my mother-in-law moved in with her family, I began checking her Explanation of Benefits because she said she did not understand why she was paying out of pocket because she also has Tricare for Life as a secondary payment to UnitedHealthcare which is a ******** advantage plan.  Since it is not traditional ********, it has different benefits, covers more and pays differently in some ways. I tried to explain that to ******************* and she refused to check her insurance and that's when UnitedHealthcare became involved.  **** and ****, both insurance representatives from UnitedHealthcare each called on separate dates and spoke with ******************* and tried to explain that their billing was incorrect.  *** then proceeded to tell the insurance representatives "that she was only doing what ************ had instructed her to do." There are multiple recorded calls with UnitedHealthcare (one on which I was conferenced in on and one that I was placed on hold for) telling *** that they needed to file the insurance because it was a "covered charge."  Her family is not the one that asked the office to file insurance, it was UnitedHealthcare that made that request which is also documented and recorded.  UnitedHealthcare has now opened up an investigation on my mother-in-law's behalf to review the billing history on her account. When I spoke with ******* at UnitedHealthcare last week on 5/31/24, she stated that all 3 visits which are 1/25/23, 7/31/23, and 2/1/24 have been filed and is being investigated. The problem that I now have is that after careful review of my mother-in-law's benefits and discussions with the insurance company it has been found that my mother-in-law's ********** & Blue Shield (PEEHIP) plan that she had from 2016-2020 and the Humana plan she had from 2020-2022 when ********** switched my mother-in-law's coverage over to them, also covered that service resulting in my mother-in-law once again paying out of pocket for "covered services." Due to no records on file with either insurance company because **************** office never filed, I now have to try and recover the money from ************ that is clearly owed back to my mother-in-law less what the insurance pays for these last 3 visits filed that could only be filed since they were within the year of timely filing. The only option we have now to recoup the out-of-pocket money paid to ************ from 2016-2022 is to either resolve this is*** with the BBB which is what I am trying to do only seeking the amount that my mother-in-law is entitled to which is approximately $915.00.  If no cooperation or resolution is met, then as the email from ******************* stated on 2/20/24, this will then become a civil suit where I will seek more than just the $915.00 for my time wasted trying to clean up this mess, and for whatever else I can *** for as well as involving ******** as an audit will be requested of **************** billing and the entire office practices. I am sending a copy of the Explanation of Benefits that I printed from UnitedHealthcare's portal showing that they are in the process of issuing a payment to ************ for my mother-in-law's 2/1/24 claim which my mother-in-law also paid out of pocket for and the other two visits 7/31/23 and 1/25/23 are still being investigated.  ********** states in their rebuttal that they filed insurance and have not yet heard back from them, so I am attaching the newest EOB for the BBB's review and can send that to their office as well.  At this point once **************** office receives that payment along with payment for the other 2 visits filed, once Tricare for Life picks up as the secondary payer, we are now crossing into insurance fraud.  I would much rather settle this outside of court, cut our ties and move on to a different physician, but I will continue to pur*** this as far as I need to until I've exhausted every avenue there is, while finding a way to bring awareness to other patients who may be in the same situation as my mother-in-law.

   Sincerely,

  
  *************************

  

  Business Response

  Date: 06/10/2024

  We were advised 10 years ago by members of our ******************** not to be billing nail care to ********.  At that time ******** was going into skilled nursing homes and charging Podiatrists with civil and criminal charges, jail time for ******************* ******** said it was not "medically necessary for a Podiatrist to trim nails.  We inform all of our patients of this and they sign a form stating that they understand ******** does not cover everything.  We follow ******** guidelines, ******** Advantage plans are supposed to follow ******** guidelines.  All my patients are aware of this at each visit, if they refuse or do not agree they can go to the nail shops or other providers if desired.  This case is closed, I am very sorry after 8 years of treating this daughter-in-laws mother now she now is unhappy with her treatment.  

  Customer Answer

  Date: 06/11/2024

   
  Complaint: 21796928
  
  I am rejecting this response because: Unfortunately you do not get to decide if this case is closed, and from where I stand it is just beginning.  Please find attached some reading material from the website for ********.gov that will show you that you are incorrect AGAIN in your response.  First of all, you will find in this material that traditional ******** requires proper coding, modifiers, and medical record documentation which they deem important for getting claims paid. It is true that traditional ******** does not cover some routine stuff, but if you read in this documentation you will find that with the correct billing methods that changes. Your medical documentation in my mother-in-law's medical records look as if they were copied and pasted in each visit. It is the same redundant wording all throughout the medical records depending on which codes you decided to use.  According to ********, the medical record documentation is questionable as to whether or not it supports medical necessity for the selection of the codes you used especially the ones that have changed or are now obsolete (attached again for your education and review). You say that ******** doesn't pay for it, but the attached information says they do if properly submitted.  NOW, in my mother-in-law's case, she is in a different category than traditional ******** and if the attached documentation from traditional ********'s website states that these services would be covered if properly coded with correct modifiers and clear medical record documentation supporting medical necessity, then I am sure you would have a practice full of patients that would love to know that they've been paying out of pocket for services that ******** would or possibly could cover if properly documented.  Also, my mother-in-law's services are not only covered under her UHC ******** Advantage Plan, but the services would be covered under traditional ******** as well because of her medical history. I've also attached information from ********.gov showing where ******** actually compares traditional ******** to ******** Advantage plans and it explains that traditional ******** doesn't cover some things that Advantage plans do and vice versa. My mother-in-law has diabetes mellitus, an unspecified nail disorder and polyneuropathy which is clearly noted in her medical records from your office, therefore, providing medical necessity for ******** to pay her claims if she had traditional ********, but again SHE DOES NOT HAVE TRADITIONAL ******** and her UHC ******** Advantage Plan covers the services! It really shouldn't be this hard as it is all in plain English on ********'s website.  The real problem is that you have never been caught or called out on you're sloppy documentation and dishonest and lazy billing practices. I am currently in contact with ******** as well as an attorney, so again this is NOT over.  I've also contacted WAFF on your side. If I were you, I would probably familiarize myself with the attached documentation so that when you are asked as to whether or not you knew about the code changes, deletion of codes, proper documentation to support medical necessity, in court when the time comes.  Or to be able to for once truthfully and honestly answer that you were told not only by me, but by UHC as well that your billing practices are wrong. In case you don't know, ******** Audits are no fun as I have been through a few in my many years of being in the medical field, watching as physicians almost lost their license for things like this. I'm prepared to do just what you asked, and that is to take this as far as I need to or to do whatever I feel is necessary in order to get a resolution.  I am doing just that if it takes me 3 years to do it and I want you to understand that I am a very persistent person I will see this through!!!
  
  Sincerely,
  
  *************************