Ajay B Setya DDS MSD

01/26/2015Re: ID# [redacted] We have reviewed the patient’s Complaint Information submitted to the BetterBusiness Bureau and would like to take the opportunity to address the issuesbrought forth by the patientWe have attempted to address these issues directlywith the patient and her spouse in December 2014, and regret to see that theirgrievances were not resolved to their satisfaction.First and foremost, we would like to address the patient’s main complaintregarding feeling as if she was provided with “insurance details.” On anyoccasion where our staff addresses our patients’ Dental Benefit information, weadhere to strict protocols with the goal of being clear that the information we areproviding is an estimate based off of the information their Dental Benefitcompany has provided to usThis is done with each patient both verbally and inwriting, specifically to prevent these types of misunderstandings.Our office has thorough documentation regarding our staff’s efforts to adhere toour protocols of addressing this patient’s Dental Benefits, including her signedTreatment Plan Estimate from 10/20/which reads:“The above information is an estimate based off the information yourinsurance company has provided us, and can change at any timeThis is nota guarantee of coverage or payment by your insurance company; coverageand payment will be decided by your insurance company upon review of theclaimFor all services rendered, applicable co-payment, deductibles, andfees for non-covered procedures are due at the time the services arerenderedWe will file the claims for your procedures as a complimentaryservicePlease note that any difference in payment from your insurancecompany and your original estimate is ultimately your responsibility.”Please see the attached copy of this document.To address the patient’s other main concern, our staff does not have anyknowledge of the patient specifically inquiring if our office is considered “In orOut-of-Network with [redacted] ” until several weeks after her procedurewas performedAccording to our documentation, the patient’s inquiries prior toher procedure were limited to the validity of the coverage information our officewas provided by [redacted] towards procedure code DPer thepatient’s request, our office confirmed coverage information towards thisprocedure code three separate times.We sincerely regret that the patient feels as if she was misled, as our officeconstantly strives to provide clear and concise information to our patientsAfterthorough review of the situation, we do not feel that the patient is due anyreimbursement from our office, as reimbursement is at the discretion of thepatient’s Dental Benefit Provider

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this proposed action would not resolve my complaint For your reference, details of the offer I reviewed appear below.I have two witnesses that will verify I asked about "In-network" pricing for both my primary insurance [redacted] and the secondary insurance [redacted] [redacted] also has on record that this office did not call or do any pre-determination of benefit as they claimed to have offered me through numerous discussionsThis office has decided and continues to provide statements about how they explained my insurance information; it is unfortunate a practice can conduct themselves in this manner [redacted] the office manager did not provide accurate information, both insurance companies have verified this with me theie clientAs a member of the medical community, I will not recommend this practice to anyone due to the nature by which they treat the clients they serve Regards, [redacted]

02/06/Re: ID# *** We have reviewed the patient’s response submitted to the Revdex.com and do not feel that the patient has any new issues to addressOur opposition remains the same

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.I have two witnesses that will verify I asked about "In-network" pricing for both my primary insurance [redacted] and the secondary insurance [redacted]. [redacted] also has on record that this office did not call or do any pre-determination of benefit as they claimed to have offered me through numerous discussions. This office has decided and continues to provide false statements about how they explained my insurance information; it is unfortunate a practice can conduct themselves in this manner. [redacted] the office manager did not provide accurate information, both insurance companies have verified this with me theie client. As a member of the medical community, I will not recommend this practice to anyone due to the nature by which they treat the clients they serve.
Regards,
[redacted]

01/26/2015Re: ID# [redacted]We have reviewed the patient’s Complaint Information submitted to the BetterBusiness Bureau and would like to take the opportunity to address the issuesbrought forth by the...

patient. We have attempted to address these issues directlywith the patient and her spouse in December 2014, and regret to see that theirgrievances were not resolved to their satisfaction.First and foremost, we would like to address the patient’s main complaintregarding feeling as if she was provided with “false insurance details.” On anyoccasion where our staff addresses our patients’ Dental Benefit information, weadhere to strict protocols with the goal of being clear that the information we areproviding is an estimate based off of the information their Dental Benefitcompany has provided to us. This is done with each patient both verbally and inwriting, specifically to prevent these types of misunderstandings.Our office has thorough documentation regarding our staff’s efforts to adhere toour protocols of addressing this patient’s Dental Benefits, including her signedTreatment Plan Estimate from 10/20/2014 which reads:“The above information is an estimate based off the information yourinsurance company has provided us, and can change at any time. This is nota guarantee of coverage or payment by your insurance company; coverageand payment will be decided by your insurance company upon review of theclaim. For all services rendered, applicable co-payment, deductibles, andfees for non-covered procedures are due at the time the services arerendered. We will file the claims for your procedures as a complimentaryservice. Please note that any difference in payment from your insurancecompany and your original estimate is ultimately your responsibility.”Please see the attached copy of this document.To address the patient’s other main concern, our staff does not have anyknowledge of the patient specifically inquiring if our office is considered “In orOut-of-Network with [redacted]” until several weeks after her procedurewas performed. According to our documentation, the patient’s inquiries prior toher procedure were limited to the validity of the coverage information our officewas provided by [redacted] towards procedure code D7953. Per thepatient’s request, our office confirmed coverage information towards thisprocedure code three separate times.We sincerely regret that the patient feels as if she was misled, as our officeconstantly strives to provide clear and concise information to our patients. Afterthorough review of the situation, we do not feel that the patient is due anyreimbursement from our office, as reimbursement is at the discretion of thepatient’s Dental Benefit Provider.

Review: I was referred by my primary dentist Dr. [redacted] to Dr. Ajay Setya for an abnormal xray. I was consulted for an abscessed tooth on 10/09/15 by Dr. Setya and then referred to Dr. [redacted] an endodontist for a second opinion on 10/16/14 at 1300 to determine my treatment and plan of care. Dr. [redacted] consulted with Dr. Setya on the afternoon of 10/16/14. I called Dr. Setya's office on 10/16/14 for results and to determine if a standing appointment on 10/20/14 for surgery was necessary. Office staff [redacted] and [redacted] assisted me with insurance questions over the phone and due to my dual coverage with Delta (primary) and [redacted] (secondary), I requested fees and in-network pricing for surgical procedure. I was informed that [redacted] would only cover surgical extraction and U[redacted] would provide the benefit for the bone graft preserve ridge and the implant. I was told by [redacted] and [redacted] my insurance benefit "was substantial and would cover 75% of the bone graft and implant." I asked for a print out of fees so I would know exactly my reimbursement since [redacted] pays the patient directly and does not reimburse the provider. [redacted] called me on 10/17/14 at 1800 to explain pre-op instructions and that I would need to pay the provider the [redacted] fee of $1448.00 prior to my surgery. My husband heard the whole conversation via speaker phone with [redacted]. I questioned the fee and coverage of insurance and she again reassured me the insurance benefit would cover up to 75% of the fee I was paying and I would be reimbursed directly from [redacted]. I asked again [redacted] on the phone for a print out of the insurance breakdown of fees and she said she was waiting for a fax from [redacted] for confirmation. I arrived to the office on 10/20/14 at 1000 for my surgical procedure. I was asked for payment but I refused to pay initially and asked [redacted] once again for the insurance benefit fee breakdown. My mother was with me and is my witness to [redacted]'s response of "I never got the fax back from friday but I can request it again and give it to you when you leave." I asked her to assure me of the benefit for the surgery and she looked at a paper she had in front of her and again repeated the 75% coverage from [redacted]. I had the surgery and asked for the fax when I left and she still did not have paperwork for me to review. I had a follow-up appointment on 11/6/14 and asked again for the insurance information. [redacted] reassured me again that Delta was billed first and just paid for the consultation so I should be receiving my reimbursement from [redacted] soon. I reiterated again to her I wanted to know the fees and actual dollars but she did not provide me with any detailed information but yet again reassured me about the 75% coverage of [redacted]. I received an EOB and check on 11/26/14 from [redacted] stating that the allowance for the bone graft preserve ridge was $186.00 and the doctor's charge/fee was $1350.00. It also stated that [redacted] was out-of-network for this provider. I was never told this information by [redacted] or [redacted] after 4 separate discussions and requests. I was misled and/or lied to about the coverage of my insurance. I called the office to see if they could help rectify the situation and [redacted] stated she explained to me the coverage but "had no way of knowing [redacted]'s fee schedule and I have never seen it that low." [redacted] also stated to me that "I also had no way of knowing the fee schedule as UC does not publish their fees and we can't get through to a customer service representative." The office never explained I was out-of-network and I asked on 4 occasions with two witnesses for this detailed information. I have $1448.00 on a care credit card that I was assured would be reimbursed at 75% coverage. I have an enormous bill; if I would have been informed correctly of insurance benefit it would have allowed me to make a more beneficial financial decision from a dual coverage standpoint. I don't feel that the office staff at Dr. Ajay Setya's practice provided me with accurate information to make an informed decision. I have spoken with a [redacted] representative about this incident and there is no request of fees from this providers office on record with the insurance company. I was also informed that the fee schedule for providers is listed on their website and the office staff could have discussed this with a [redacted] customer service representative. I am in the medical field and am extremely disappointed in the service I was provided by the office manager and staff at this practice. As an individual who pays for two insurance premiums through two employers for dental coverage this is an avoidable situation. I don't feel this practice had my best financial interest at hand. I would have made a different choice of a provider if I was not misled with false insurance details. This is a service this office chose to provide me as a customer and it was wrong and now I have to pay the consequence financially for this mistake. I appreciate the Revdex.com looking into this matter with this physicians' office. Thank you,[redacted]Desired Settlement: It would be fair for the practice to honor their information given to the patient on insurance reimbursement. A fee of 1350.00 was billed to [redacted] with a reimbursement of 75% of the allowed fee. [redacted]'s fee was 186.00 for this procedure so I would be liable for about $65.25 according to the EOB. The practice failed to tell me this part of the treatment was "out of network" therefore they should accept the fee schedule due to misleading the patient on insurance information.

Business

Response:

01/26/2015Re: ID# [redacted]We have reviewed the patient’s Complaint Information submitted to the BetterBusiness Bureau and would like to take the opportunity to address the issuesbrought forth by the patient. We have attempted to address these issues directlywith the patient and her spouse in December 2014, and regret to see that theirgrievances were not resolved to their satisfaction.First and foremost, we would like to address the patient’s main complaintregarding feeling as if she was provided with “false insurance details.” On anyoccasion where our staff addresses our patients’ Dental Benefit information, weadhere to strict protocols with the goal of being clear that the information we areproviding is an estimate based off of the information their Dental Benefitcompany has provided to us. This is done with each patient both verbally and inwriting, specifically to prevent these types of misunderstandings.Our office has thorough documentation regarding our staff’s efforts to adhere toour protocols of addressing this patient’s Dental Benefits, including her signedTreatment Plan Estimate from 10/20/2014 which reads:“The above information is an estimate based off the information yourinsurance company has provided us, and can change at any time. This is nota guarantee of coverage or payment by your insurance company; coverageand payment will be decided by your insurance company upon review of theclaim. For all services rendered, applicable co-payment, deductibles, andfees for non-covered procedures are due at the time the services arerendered. We will file the claims for your procedures as a complimentaryservice. Please note that any difference in payment from your insurancecompany and your original estimate is ultimately your responsibility.”Please see the attached copy of this document.To address the patient’s other main concern, our staff does not have anyknowledge of the patient specifically inquiring if our office is considered “In orOut-of-Network with [redacted]” until several weeks after her procedurewas performed. According to our documentation, the patient’s inquiries prior toher procedure were limited to the validity of the coverage information our officewas provided by [redacted] towards procedure code D7953. Per thepatient’s request, our office confirmed coverage information towards thisprocedure code three separate times.We sincerely regret that the patient feels as if she was misled, as our officeconstantly strives to provide clear and concise information to our patients. Afterthorough review of the situation, we do not feel that the patient is due anyreimbursement from our office, as reimbursement is at the discretion of thepatient’s Dental Benefit Provider.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

I have two witnesses that will verify I asked about "In-network" pricing for both my primary insurance [redacted] and the secondary insurance [redacted] also has on record that this office did not call or do any pre-determination of benefit as they claimed to have offered me through numerous discussions. This office has decided and continues to provide false statements about how they explained my insurance information; it is unfortunate a practice can conduct themselves in this manner. [redacted] the office manager did not provide accurate information, both insurance companies have verified this with me theie client. As a member of the medical community, I will not recommend this practice to anyone due to the nature by which they treat the clients they serve.

Regards,

Business

Response:

02/06/2015 Re: ID# [redacted] We have reviewed the patient’s response submitted to the Revdex.com and do not feel that the patient has any new issues to address. Our opposition remains the same.