Complaints

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• Initial Complaint

  Date:09/29/2022

  Type:Customer Service 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.

  My son's due for an upgrade on his cochlear implants every 5yrs. through insurance. All we have to do is see the Audiologist & ENT then Medel files the proper ppwk to Ins. His upgrade was due July 2021 The appointment with the audiologist was rescheduled due to the doctor having something come up. We were pushed to 1/22. Late October his left cochlear hook came off, but it's no longer covered under his warranty. We planned to have it replaced. On 12/21 our home burnt to the ground including ALL EQUIPMENT & 5 processesors. The day before his appt with the audiologist. in Jan. We got a call to reschedule the appt because the doctor wasn't in again. I threw a fit, my son's been without a left cochlear since late October & we have zero equipment to maintain his right cochlear. I got ahold of someone who assured me they'd get this ratified. Audi.'s office submitted a letter of medical nessesity (LMN) to Medel & Ins trying to bypass going in. I kept being told by Medel "it's processing." Received a denial letter in March so I rescheduled him to the Audi's first available 6/17 we saw the Audi & ENT that week. Both submitted ppwk to Medel. Waited until Aug to reach out & see what the hold up was & told by **** ****** with Medel that an appeal was submitted on 8/25 to request reconsideration. I called Ins, no record of an appeal or current claim pending. Also, the appeal time limit had already been reached for the 3/22 claim. I emailed **** letting her know what ins said. She claimed she had a ref# & name of who she filed with. I thought maybe it just needed more time to reflect in the acct. So I gave her more time but then **** kept requesting the same ppwk she'd already received from the Audi for LMN. So his audi and myself re-sent them several more times via email. I called Ins again. This time they had a record of an appeal but no current claims. **** stated several times via emails she filed an appeal on 8/25, ins said she filed on 8/29 which was not only two months-

  

  Business Response

  Date: 10/05/2022

  MED-EL’s
  goal is to provide prompt and efficient service, and we appreciate the
  opportunity to rectify any customer concern that is brought to our attention as
  soon as possible.  We have investigated the incident to determine the
  factors involved in causing this unfortunate delay. Unfortunately, there were
  delays in their being seen by their local clinical Providers (which is a
  necessary step to initiate the medical documentation required for insurance
  approval of a new system). We worked with the local clinical team to submit the
  request for coverage (despite their not having been able to be seen), but this
  resulted in an insurance denial of coverage (since they typically require the
  User to be seen and require documentation from the medical record to support
  this).  MED-EL Reimbursement staff requested the required medical
  documentation on 3/23/22.  The Insurer’s request for a peer-to-peer call
  with the User’s Physician was sent to clinic on 4/08/22. There was a change in Audiologist during this time,
  and their new Audiologist wasn’t sure which system to order until they
  consulted with the family (after which they promised to send the medical
  documentation that we are required to submit to insurance with our
  request/appeal, including Clinical Notes from the Clinic’s medical record. We
  did not receive the clinical notes required for the submission until 8/25/2022
  (and did follow up with the local clinic during this time to try to obtain
  them).  We submitted the appeal to User’s Insurer on 8/25/2022.  We
  were informed on 9/8/22 that appeal was closed by the insurer because the
  original Prior Authorization (for the equipment this user needs) submitted on
  3/17/22 did not contain the medical records from the local clinic supporting
  the medical necessity to replace the original equipment and the date of
  purchase of that original equipment. On the same date, 9/08/22, Insurance
  advised we needed to resend our appeal, and it was re-submitted that day.  In response to follow-up calls to insurer to
  check status of appeal, MED-EL was advised that they had classified the case as
  “peer to peer”, which this insurer defines as their assignment of one of their
  internal medical directors to review and determine if a formal review between
  insurer medical director and patient’s surgeon is required to overturn their
  authorization denial.  Insurer also advised MED-EL that they require
  completion of the Title XIX forms by referring surgeon before they will review
  case further.  MED-EL requested
  the patient’s referring physician to complete and sign the Title XIX forms on
  9/21/22 (after receiving the forms from Amerigroup).  We updated the
  family on the same day (of the Insurer’s response and what was required to
  proceed with the appeal).  We received the Title XIX forms signed by the
  Physician on Friday evening (9/30/22) and submitted those to the Insurer on
  Monday 10/3/22. MED-EL Reimbursement staff have been in contact with the family
  to update them on the progress of this appeal.  We received an email
  Friday (9/30/22) from the family requesting to change the order from ***** to
  ****** (Speech Processors), and this change will be honored upon resolution of
  the insurance approval and order completion. The next step is for Amerigroup to
  process the appeal that the patient’s mother filed by phone on Thu, Sep 29th.
   MED-EL was advised by phone follow- up to insurer on Monday, Oct 3rd that they would not consider the member’s appeal until member returns insurer’s
  forms. Insurer estimated processing of appeal to take 30 days after forms
  received from member. The insurer may determine that a formal peer-to-peer
  review is necessary at the conclusion of their review of the appeal.  
  
  We
  understand the frustrations of this User and family. They have been through a
  horrendous year, and all the delays are understandably frustrating.  We
  provided a quote (for the equipment) for FEMA, after the family’s fire last
  December, but never received confirmation of coverage by FEMA (which I’m sure
  added to the family’s frustration). [I think this sentence is confusing –
  MED-EL was not involved with the FEMA situation beyond providing a quote to
  family should they need it to submit to FEMA. Our staff have worked to obtain
  the information necessary from the User’s local medical Providers to file a
  Prior Authorization request for coverage; followed up regularly when there were
  delays in obtaining additional documentation requested/required by the Insurer;
  have tried to facilitate the steps necessary for the Insurer to consider our
  appeal of their denial of coverage and will keep the family updated as this
  progresses.  If Insurance approves coverage, we are ready to ship the
  equipment ordered by the User’s Audiologist.  If insurance coverage is
  denied, we will reach out to the family and their local medical Providers to
  discuss options and see how they want to proceed.
  
  We
  do not consider this situation resolved but are doing all we can to try to get
  approval from their health Insurer. We will continue to follow up, keep the
  family and local Providers updated as to the status of our appeal of the
  Insurer’s denial of coverage, and based on their Insurer’s response, work with
  them to find a solution so that this User can obtain the equipment they need.