Advanced Cardiac Surgical Associates, PLLC

This letter is in response to a complaint submitted on 9/28/with an assigned ID number of [redacted] Mr [redacted] came in for a consultation on September 5, In which a bilateral Duplex Ultrasound was done and a formal consultation performedThe fee we charge insurance companies is the standard Specialist office visit fee we charge every insurance company and the same fees other Specialists chargeThe CPT code submitted to the insurance company depends upon the level of consultation performed and the type of scan performed which are two different billable CPT codesEach insurance company decides what amount it will approve and what amount will be paidFor example, if we submit a bill for $700.00, the insurance company may approve $450.00, and then pay $300,and may require the patient to pay another $requiring the rest to be written offThus, from this example, a submitted $bill, we would only be paid $400,and be required to write off $Every patient signs our payment waiver stating that in the event the insurance does not pay for the entire visit, they are responsible for the differenceIt is impossible for us to determine what a patient will be responsible for in advance because there are over 10,insurance plans and we would have to employ several thousand people to know in advanceEach patient, as required by law, is given a one to two-page informational sheet from their insurance company in January of each year which explains their deductibles,co-pays, etcWe inform all of our patients that we will submit the claim to their insurance companyWe also advise them to contact their insurance company to inquire about their benefits and to find out what their responsibility may beThis patient has a deductible plan not a copay planAt the time of his visit, his deductible was $1,500,and he had only paid $towards his deductibleA deductible plan means that patients must pay their out-of-pocket maximum before the insurance company will start paying in full to any physician or medical practiceIt is ultimately the patient's responsibility to know their insurance policy and what is required of themThank you for your time and attention regarding this matterIf you have any additional questions, please do not hesitate to contact me at ###-###-####Sincerely, Karen KAdministrator

I'm writing in response to your letter regarding a complaint you received from the above named patientPer my phone conversation with you, I am unable to fully disclose all information available as the matter with our current Electronic Medical Record Vendor (hereinafter "EMR"), *** * ***,
LLC's Interface MD program (hereinafter "***"), has become a legal matter
Regarding the patient's complaint, I will address each of her statements individually
"I had gone to the office for the same treatment on two different occasions."
This patient had been seen at our office a total of six (6) times, three (3) of which were for the same procedureShe was seen in consultation on March 25, and had two (2) other follappoints on May 10, and May 22, The patient had the same procedure on July 2, 2013, October 22, and February 4, She did cancel her June 10, appointment for another procedureIt should be noted, the patient's medical condition requires treatments every three (3) to six (6) months to control her condition
"The visits were billed differently and the women in billing told me they weren't and when I explained how they were different she responded well it doesn't matter we wrote charges offThere was nothing written off by the office, and my insurance can not help me because it is an issue with the office" The procedure was billed the same all three (3) times the patient came in for the procedure, units of BotoxThe difference for the later date of service, February 4, was it was only billed as one injection versus injections which was billed for the earlier visit on July 2, The insurance company corrected us with the billing for the July 2, 2013, stating even though we did injections of Botox, the injections and amount of Botox used should not be the same, meaning we bill the amount of units of Botox being used and only one injection even though injections were doneTherefore, the bill was adjusted to the one injection
As far as the biller stating, "It doesn't matter we wrote charges off," it is falsePer Federal Law, we are not able to write off charges unless the insurance company tells us we are required to write off charges or it is considered upcoding and a chargeable offenseIn this patient's situation, her outstanding bill is for her deductible, meaning her insurance company does not pay for medical care until the patient's deductible is met each yearThe responsibility for knowing whether or not there is a deductible or coinsurance, the amount of the deductible, and the amount of deductible the patient has met for the year is solely the responsibility of the patientThere are thousands of plans *** *** *** *** administers and it is impossible to know which plan the patient's employer purchased for herUnder the law, insurance companies are required to send their insured all information regarding their plan every year which includes their annual deductible amount, coinsurance amount, and their copay amountTherefore, this patient knew or should have known the amount of her deductible and the amount she has paid towards her deductibleWe would have no way of knowing how many doctors she had seen or how many tests she may have had done prior to seeing us and the amount of deductible she paid towards those visits
It should be noted, the patient never brought up the issue in her complaint that she was also treated on October 22, 2013, at which time she had the same procedure as she did on July 2, and February 4, Since she had met her deductible by the October 22, procedure, the patient only had a copay due for that date of serviceBased upon the patient not raising this visit in her argument, it is clear she was aware of having to meet a yearly deductibleI have enclosed a copy of her billing statements for dates of service July 2, 2013, October 22, 2013, and February 4, for your reviewIt should also be noted; the patient originally had *** *** as her insurance prior to having the July 2nd procedure*** *** is an HMO and the patient was only responsible for her copayOn her May 10th visit, the patient presented her new insurance card with coverage now being through *** *** *** ***When she received her new insurance card, she received the benefit package information which stated her deductible amount
What is most concerning is this patient was employed by a doctorThus, she should know more than the average consumer about insurance plansAdditionally, when a claim is submitted to *** *** *** ***, the patient receives an explanation of benefits (hereinafter,"EOB") which states the amount billed, approved, amount to adjust off, amount paid, deductible, coinsurance and copay amountIf the claim is denied, it states on the EOB, the reason for denialThese EOB's are sent directly to the patients by insurance companies to inform them a physician has submitted a bill for services renderedThis is done by the insurance companies to detect fraudulent billing activitiesI have enclosed a copy of a recent EOB I received from *** *** *** *** for care rendered by a non-participating providerAs you can see, the EOB clearly states on my claim I am to pay a deductible
In this case, the patient should've received an EOB from *** *** stating the amount we billed, what was paid, what was denied, and what was the amount she needed to pay as her deductible*** *** *** *** would be able to verify the dates the EOB's were sent to the patientTherefore, the patient knew she was responsible for her deductible and the amount she owed us prior to us receiving her EOB from *** *** *** ***
As far as *** *** *** *** stating to the patient that they cannot help her because it is an issue with the office, I cannot confirm or deny it because I was not privy to the conversationWhat I can tell you with a 100% certainty is if it was an issue with our billing, *** *** *** *** would've called our office and told us we either needed to resubmit the bill or we are required to write it offSince we did not receive a call from *** *** *** ***, I am assuming they told the patient the bill is for her deductible and therefore, they could not help her with it as it is a requirement that must be met under her plan before they pay
'The women also told me she would call me back and never did."
The biller had spoken to this patient on a few occasions and informed her that *** *** *** *** through their EOB told us she is responsible for the bill because her deductible has not been metIt was also discussed with her the delay in her receiving a bill due to the EMR system incorrectly and automatically writing off denied claimsThis issue had been raised several times with ***As I stated earlier, we have no idea how many physicians or tests she had done prior to seeing us to know whether or not she has met her deductibleWe only find out when *** *** *** *** sends us the EOBIt is the patient's responsibility to know her insurance plan, her deductible amount and how much of the deductible she has metShe was also told that we cannot write off deductiblesThe patient stated her mother was a medical biller and was going to call us to discuss the billHer mother never called the officeIt is not our responsibility to call the patient back and tell her that her mother did not call us
"I also sent a letter explaining all the issues I was having with the billing and he never responded."
I'm not sure who "he'' is as the patient states she has spoken with women in billingI personally handle all of the mail and any issues in the officeI have never received any complaint from this patientHowever, my response would've been the same as billing; we are unable to write of her deductibleIt is illegal to write off deductibles and I am not going to risk the physician'slicense by committing fraud against the insurance companyAdditionally, we pay for the Botox which is quite expensive in addition to all of the needles, syringes, alcohol wipes, ice packs, etcthat is used for the procedureWe cannot afford to do procedures for free because a patient doesn't want to pay their deductibleWe didn't choose her insurance plan for her, she or her employer did and we are required to abide by the law
When I went in for the second appointment I was told I had no balance on my account, I had received my bill far the second visit and called to ask why it wasn't covered and I was then informed I have had an outstanding balance on my accountI did not know about this, and feel like I was lied to and now owe more money then I would have, had I known about my balanceI believe the patient is referring to her fourth (4th) visit which was her first procedure on July 2, She had three (3) appointments prior to the July 2nd visit*** *** *** *** paid this patient's claim for her July 2nd visit on August 6, after a request for procedure notes for the July 2nd procedureThe insurance company adjusted a total of $off of the original claim and stated the patient was responsible for $as her deductibleThis claim was never denied as *** *** *** *** stated the patient had not yet met her deductible and therefore, is responsible for the billA patient bill was generated on August 6, after payment was posted and mailed to the patientThis patient was well aware of the amount she owed this office
The patient now claims when she went in for her second visit, she received a bill and called to ask why it wasn't covered and was informed that she had an outstanding balance on her account, but didn't know, felt she was lied to and owes more money than she would've had she known about the previous balanceThis patient has blatantly lied about knowing about her deductible and knowing she had a balanceIf the patient is truly talking about her second visit to this office, that was on May 10, The bill was submitted for $and *** *** adjusted off $on June 4, 2013, leaving the patient a balance of $as her responsibility for her deductibleShe was seen again on May22, for which a bill was submitted in the amount of $and *** *** adjusted off $on June 11, leaving the patient a balance of $as her deductibleOn August 29, 2013, the patient paid via check number *** $for the May 10th visit and $towards the May 22nd visitShe also paid $by way of *** for the May 10th visit on May 22nd and $towards the May 22nd visit on that day by ***Therefore, by having paid with check number ***, the patient was well aware she had to meet a yearly deductible
If the patient means her second appointment as being her second procedure, then that date is October 22, 2013, not the February 4, date she is claimingThe patient's first procedure was on July2, She had the exact same procedure on October 22, This bill was paid by *** *** *** *** on November 12, and since the patient had met her deductible, she was only responsible for her copay which she paid at the time of her visitThe patient came in for her third (3rd) procedure on February 4, and *** *** *** *** adjusted off their amount and stated the patient was responsible for the bill as it is her deductibleThe patient was well aware that every January 1st, she is required to meet her deductible for the year prior to *** *** *** *** paying medical expenses as she received her EOB from them before we didAdditionally,as stated earlier, the patient received her packet from *** *** *** *** stating she had a yearly deductible that must be met prior to them paying claims
The patient refers to the February 4, as her second procedure and stated she was told at this visit she did not have a balanceThat is impossibleHer appointment was at 5:pmAt that time, there were only two people who had access to billing information, one being the biller, who leaves at pm and the other being myselfI have not been asked to look up a patient's balance in well over a yearIf she had truly asked the girl at the chewindow, she would've been told by them that they don't have accessAccess to the billing system is limited because it is sensitive information
No one at the office answers my questions or calls me back."
This was already addressed under number three (3) above
The patient requests: "I would like my bills to be corrected, and the office to be held accountable for part of the money I owe because I was told I had no balance when I went inHad I known I still owed money I would not have kept the second appointmentI would also like to hear from the doctor so I can inform him of how rude the women in billing was to me." There are no bills to be corrected in that the deductible cannot be written off
Simply put, the patient knew she had a yearly deductible from her initial packet received from *** *** *** ***, the yearly informational packet she receives from *** *** *** *** as required by law, the deductible payments she made for her May 10th and May 22nd visits, the EOB's she received from *** *** *** *** for every visit she had with us indicating from them that she owes the amounts as deductibles, and the bills she received from usAs I have stated earlier, if *** *** *** *** felt we had inappropriately billed, they would've called us directly to correct the matter and they never calledThe patient herself admits *** *** *** *** said they couldn't do anything which I'm almost certain they told her that she has to meet the deductible before they would cover her medical expensesLastly, we cannot write off her billIt is illegal
If we were to write off her bill, it would be considered upcoding and the doctor could be charged for fraudulent billingSince we were required to pay for the Botox, supplies, staff etcused in this patient's procedure, the patient is responsible for her portion of the expenseAdditionally, the patient signed a private pay waiver which clearly states she will pay her balance of the bill for visits and/or proceduresCorrections were made to her July 2, from a $overpayment made on August 29, to the May 22, bill, and from a $copay overpayment made on October 22, Her July 2, bill now has a balance of $The error in not automatically being able to apply an overpayment to a patient's account is a programming issue with *** has been aware of this problem for several years now and has repeatedly stated he would correct the issue, but hasn'tHis EMR does not allow you to see any credit balances while posting or billingAs I have stated to you by phone, *** has closed doors and we are in the process of switching to a new vendorI hope this answers your request for informationAgain, I have enclosed copies for your reviewIn addition, you are more than welcome to come to the office to review the dates of the patient's visits as well as the exact times she arrived and was treated on our EMR systemIf you should need any further information, please do not hesitate to contact me at ###-###-####
Sincerely,
*** ** ***, Esq
Office Manager

This letter is in response to a complaint submitted on 9/28/2017 with an assigned ID number of [redacted]. Mr. [redacted] came in for a consultation on September 5, 2017 In which a bilateral Duplex Ultrasound was done and a formal consultation performed. The fee we charge insurance
companies is the...

standard Specialist office visit fee we charge every insurance company and the same fees other Specialists charge. The CPT code submitted to the insurance company depends upon the
level of consultation performed and the type of scan performed which are two different billable CPT codes. Each insurance company decides what amount it will approve and what amount will be paid. For example, if we submit a bill for $700.00, the insurance company may approve $450.00, and then pay $300,00 and may require the patient to pay another $100.00 requiring the rest to be written off. Thus, from this example, a submitted $700.00 bill, we would only be paid $400,00 and be required to write off $300.00. Every patient signs our payment waiver stating that in the event the insurance does not pay for the entire visit, they are responsible for the difference. It is impossible for us to determine what a patient will be responsible for in advance because there are over 10,000 insurance plans and we would have to employ several thousand people to know in advance. Each patient, as required by law, is given a one to two-page informational sheet
from their insurance company in January of each year which explains their deductibles,co-pays, etc. We inform all of our patients that we will submit the claim to their insurance company. We also advise them to contact their insurance company to inquire about their benefits and to find out what their responsibility may be. This patient has a deductible plan not a copay plan. At the time of his visit, his deductible was $1,500,00 and he had only paid $926.17 towards
his deductible. A deductible plan means that patients must pay their out-of-pocket maximum before the insurance company will start paying in full to any
physician or medical practice. It is ultimately the patient's responsibility to know their insurance policy and what is required of them. Thank you for your time and attention regarding this matter. If you have any additional questions, please do not hesitate to contact me at ###-###-####. Sincerely, Karen K. Administrator

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
1. I know I had gone more than two times, the two times I mentioned were the two bills I was questioning. 2. The two bills I was referring to were different and billing did not explain to me why. She just kept saying they weren't different and she knows what she is talking about. I was told charges were written off by the office and the bills are fine. This did not make sense to me because nothing was reflected on the bill showing this. I kept trying to ask for an explanation and all she had to say was I've been doing this for many years, I think I know what I'm doing.I understand I have a deductible, but I know sometimes insurance plans cover certain procedures even if a deductible is not met. I had sent in a check, for an earlier visit, and then stopped receiving bills in the mail, so I was under the impression my insurance covered the costs. When I went in October it was never mentioned that I owed anything when I checked in at the desk. I was just told all I owed was the copay. Just because I worked for a doctors office does not mean I know about medical billing. I was receptionist and had no part in billing or insurance plans for the office. I only answered phones, took messages for doctors, and made appointments. When I spoke to [redacted] they did not understand why the bills were different and told me it was an issue with the office and I would have to talk to them about the issue. To assume [redacted] told me it was my deductible is wrong because they tried to help as mush as they could and told me I would need to speak to the office to resolve the issue.3. I did tell the woman in billing my mother would be calling, and even after that she told me she would call me back the next day. I never received a call back from her.  Also she had told me I was in a basket to go to collections because of unpaid bills. I looked at their bills and nowhere is it stated what their policy is. Because of not receiving bills this is why I thought my insurance had paid for the visit.  
4. I sent a letter to Dr. [redacted] with all my questions and concerns. I mailed it to the office in [redacted]. 5. The second appointment I was referring to was in fact the Feb. 4 appointment. I know this was not my second appointment or procedure. It was the second procedure of which I was questioning. When I checked in I did in fact ask about my account. I was not told they don't have access to billing, I was only told all I owed was the $45 copay. I do not know who does and does not have access to billing. If she did not have access she should have told me to speak with billing. 
Regards, [redacted]