Complaints

This profile includes complaints for Prairie States Enterprises, Inc.'s headquarters and its corporate-owned locations. To view all corporate locations, see Find Local Branches.

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  Prairie States Enterprises, Inc.

  615 Pennsylvania Ave Sheboygan, WI 53081-4642

  
• 

  Prairie States Enterprises, Inc.

  PO Box 23 Sheboygan, WI 53082-0023

  

The complaint text that is displayed might not represent all complaints filed with BBB. Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business.

• Initial Complaint

  Date:09/22/2023

  Type:Service or Repair 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.

  On 9/11, my minor child, *************************** was seen by ******************************** for her breathing problems caused by what we thought at the time were her tonsils. As noted in her chart, ***************** assessed her of having Chronic Hypertrophy of tonsils and adenoids and sleep disorder breathing due to the primary issue. Her insurance agent Prairie States Enterprises informed us the day before their surgery that they were denying the claim. They claimed it was due to lack of information on the doctor's part and lack of imaging. They claimed to have done due diligence, but I believe that they are unnecessarily making an 11 year old child who has complained about sleeplessness and being tired all the time go through thousands of dollars of unnecessary tests. The Doctor said, "In my twenty years of practicing, no other insurance company has asked for this much information regarding a simple procedure."

  

  Business Response

  Date: 10/09/2023

  Complainant:*************************
  Member Name: *****************************
  Patients Name: ***************************
  PSE Case:**********
  
  Prairie States Enterprises (PSE) is a Third-Party Administrator for the Muskego-Norway School District. This is a self-funded, non-grandfathered, federal ERISA plan.
  
  Below are the notes in regard to this case request. Currently, the request for appeal has been completed and the request was overturned and approved as medically necessary.
  
  PSE received the request for ***** Removal of Tonsils and Adenoids on Sept 14,2023. This is a standard pre-service request which is allowed 15 days to complete the decision. Upon ********************** review of the request compared to the appropriate medical guidelines (MCG), was not able to approve the request as there was no information on observed obstructive sleep apnea and no formal assessment of adenoids (x-ray/assessment). The request was sent to MD review of the clinical information, medical plan document, and associated guidelines. Upon sending the request for MD review, the ********************** nurse sent a letter to the provider notifying of the MD review and that a peer-to-peer call *** occur during that time.
  
  Based on the review of all information available, the MD review determined the following: Tonsillectomy and adenoidectomy would be supported by scientific literature for the treatment of sleep disordered breathing and would not be considered investigational/experimental. All records were reviewed.  There is not documentation of apneic episodes reported by the patient's family.  There is also no documentation of the status of the adenoids by either x-ray or exam.Therefore, based on the information provided, the medical necessity of the *** ***** is not confirmed. Obtain further history to assess for Obstructive Sleep Apnea (OSA) or obtain a sleep study. In addition, adenoid assessment is recommended.
  
  Once the decision was complete, a determination letter with appeals rights were faxed to the provider and mailed to the member on Sept 21, 2023. The ********************** nurse also called the mother (*********) to review the denial with her and the available appeals rights.
  
  The same day, father (****) began calling PSE offices to speak to a manager about the decision. **** had his call returned the same day Sept 21, 2023. During the call, the denial and appeal rights were explained. Items for the appeal were suggested and explained that we needed a signature, etc. The father (****) expressed upset of the decision and requested it be approved immediately based off his phone call complaint of denial. The appeals were again reviewed as the only available option.
  
  PSE received the appeal request with an associated radiology result assessing the adenoid structure and associated diagnoses. The x-ray was completed post-denial. The appeal was received, and process began on Sept 25, 2023. All the information on this case request was sent to a separate MD reviewer who determined the below information. This resulted in an approval/overturn of the request. The appeal letters of approval were sent to the member and provider on Sept 28, 2023.
  
  The approval decision is as follows: According to the medical records, the claimant is an 11-year-old female with a date of birth of 01/05/2012 who presented with sleep-disordered breathing. Examination revealed 3+ tonsils and imaging corroborated with the findings of enlarged tonsils and adenoids. Nasal steroid spray was trialed without benefit. The claimant reported issues with breathing and snoring. The request was previously denied stating more information is needed, such as a sleep study or adenoid hypertrophy to support the procedure.There is a positive history of similar complaints necessitating adenotonsillectomy.The procedure is well-supported within the literature.
  
  Based on the review of the entirety of this case, the decision was completed appropriately via the MD reviewer, decisions were completed in a timely manner,and results of the determination were both submitted in writing and verbally with all associated appeal rights and responsibilities to both parents of the dependent.  
  
  As the appeal process was followed and additional information submitted, the claim is now approved and considered medically necessary.
  
  Please let me know if you require further information.

  Customer Answer

  Date: 10/09/2023

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
  

  During the first determination of the medical necessity of the surgery, we received no copy of the medical guidelines (MCG) that were rejected.  In addition to that, as noted in the letter no peer-to-peer call took place.  I feel that Prairie States played the pronoun and anonymous reviewing body name game with us to disapprove the surgery.  Our doctor noted that in her twenty years of practicing this was the most level of detail she has ever had to go through.  In addition a study in the Otolaryngol Head and Neck Surgery case studies published on the *** website (*****************************************)  Found that only 1.5% of all claims of tonsillectomy were rejected and that "the value of PA for pediatric tonsillectomy is questionable". 

  The affect of their lack of response and lack of communication with her actual pedestrian resulted in a delay of surgery of three weeks of her not being rested at night and her having breathing difficulties.  I feel the business used arbitrary guidelines and not best general practices that other big insurance companies use.  I feel an adequate resolutions to this issue is a change in ******* and an apology to my daughter for the three week delay in the surgery approval.

   

  ****

   

  
  Regards,
  
  ******************************

  Customer Answer

  Date: 10/23/2023

  I still feel Prairie State have accepted zero responsibility for the timing of these issues and I have not received an apology from

  Management and they have not indicated that they will review best practices on their end to make this better for consumers.  I would tell an HR authority if they are thinking of hiring prairie state enterprises as their health care administrator not to do so. They needlessly made my daughter suffer for three weeks more than what her medical doctor thought was necessary.  Without a formal apology and a certainty to review how they approve cases, I will continue to complain to anyone who will listen.