American Specialty Health Inc

This company is one of the worst cases of a monopoly that I've ever seen. They force providers to be in network with them if they want to take blue cross insurances and seeing that most policies don't have out of network coverage, the patients will have to pay 100% of doctor costs if they don't accept their lower than medicare fee schedule. Just so everyone knows, they reimburse doctors at a rate of $0.80 per minute......that's less than a massage therapist. What this company does should be illegal, it's a shame they're even allowed to pull some of the crap they do.

Review: The agent on the phone failed to say the "the yearly fee of $25.00 was not refundable if we cancelled the agreement within a reasonable time frame. We agreed to the health plan on August 12, 2013 and called that same day to cancel the "deal" because it did not fit our use of the health club that we use.

We've tried multiple times to call 877.427.4788 but get the same response that the fee is "non-refundable"Desired Settlement: We want those separate $25 ($50) to be refunded to our Discover account

Business

Response:

RE: Response to Complaint Filed with the Revdex.com (Complaint ID [redacted])

American Specialty Health (ASH) received your complaint from the Revdex.com (Revdex.com) related to your concerns about your enrollment payments made to Silver&Fit for your fitness program provided by your insurer, HealthPartners. Silver&Fit is a subsidiary of American Specialty Health, Inc.

Silver&Fit has researched the issue and found that you did contact our customer service team to enroll with a fitness club on 8/12/13. We also show that you called to disenroll the same day. While the materials distributed during open enrollment with HealthPartners indicate that the enrollment fee of $25 per enrollee per year is non-refundable, the customer service agent did not provide this information at the time of telephonic enrollment on 8/12/13. Therefore, we are making an exception to our non-refund policy to refund you for your enrollment fee totaling $50. You can expect to receive this refund as a credit on your charge account within 4 weeks from the date of this letter.

Should you have any further questions, please contact me directly at 800-972-4226 extension [redacted].

Sincerely,

Review: I was told by three different representatives at ASH that my benefits could be used differently than they are now informing me. They will not take responsibility for giving me the incorrect information. ASH should have to pay for the befefits they said I had. I even verified yesterday about the information given to me and suddenly today it has changed. Now I've had to cancel appointments and sit in pain because of ASH's misinformation.Desired Settlement: I want to be able to use all of my chiropractic visits I can fit in by the end of the year, I was told as long as I didn't exceed the yearly maximum of 24 that they would be covered, ASH should cover these.

Business

Response:

ASH has contacted the complainant directly and resolved the case. I have spoken directly to Ms. [redacted] and her chiropractor. ASH will be honoring the unlimited visits for Ms. [redacted] for the calendar year of 2015 based on [redacted]'s direction. I provided Ms. [redacted] my direct contact information for anything further. She can reach me by email at [redacted] or by phone at ###-###-####. Thanks[redacted]American Specialty Health

Review: They maintain that because of law they cannot send me claims correspondence electronically that they must send copies to me by snail mail of everything they send to my chiropractor. This company is a sub-contractor of CIGNA yet they do not offer an electronic/email option for correspondence like they do.Desired Settlement: I demand that they comply with my request for an electronic/email option for this correspondence. My argument is that they would still be HIPAA compliant and would save time and money for their business in the long-run, plus they would also then be in compliance with the Paperwork Reduction Act. I have no use whatsoever for the reams of paper and envelopes that they send me. It all gets recycled. It is a waste of trees. I have asked them multiple times to change their policy, but they claim "it's the law". I think they are just lazy.

Business

Response:

Please see attached letter to the complainant that was placed in the mail today.

August 7, 2013

RE: Response to Complaint Filed with the Revdex.com (Complaint ID [redacted])

American Specialty Health (ASH) received your complaint from the Revdex.com (Revdex.com) related to your concerns about written correspondence from ASH.

While ASH understands that you desire to receive required notices from ASH via email or online, we are not able to accommodate that request at this time. ASH will have to continue to send correspondence via US mail as permitted by HIPAA and state laws involving such notices

In regard to your reference to the Paperwork Reduction Act, this act is designed to reduce the total amount of paperwork burden the federal government imposes on private businesses and citizens. The Act imposes procedural requirements on agencies that wish to collect information from the public. To this extent, it is ASH’s understanding that this law does not impact ASH’s operations or preempt state laws otherwise permitting the member communications you’ve noted to be sent via mail.

ASH appreciates the feedback and strives to provide excellent customer service to those we serve. ASH will continue to evaluate opportunities for service improvement and will implement changes as priorities are identified.

Should you have any further questions, please contact me directly at ###-###-####.

Sincerely,

Senior Manager, Clinical Operations

American Specialty Health

Review: American Specialty Health contracts with [redacted] of California. They are suppose to share information and update them accordingly. I am a Chiropractor and I recently changed my clinic address. I had notified both companies. It had been two months and still, the address is not changed. I called [redacted] and they said ASH is suppose to send the information. I called ASH and they said they had sent the information. Both companies refuse to contact each other to resolve this issue and I am stuck in between without getting paid for two month - and counting.

I had called ASH numerous times, and they said the person in charge is not available and that they would call back once she steps into the office. It had been two weeks, and they never called. ASH promised a 4 to 8 weeks processing time to update clinician information, and that time had already past. I just called today and they told me to wait another 4 to 8 weeks. That is simply unacceptable.Desired Settlement: Finish the job that American Specialty Health promised to do. It is a simple address change and they can drag this thing on and on. Unacceptable. I want ASH to fix this whole mess and get my clinic information updated with the companies they contract with.

Business

Response:

RE: Response to Complaint Filed with the Revdex.com (Complaint ID [redacted])

American Specialty Health (ASH) received your complaint from the Revdex.com (Revdex.com) related to your concerns about your office address update with ASH.

ASH has researched the issue and does show that you submitted your address update to ASH on 6/4/13 requesting the effective date of the change to be 6/4/13. While your agreement with ASH requires a minimum of 60 days notice for an address change, ASH was able to make an exception and make your new address effective in ASH’s system 6/4/13. However, ASH is unable to make such exceptions when reporting provider changes to contracted clients, such as [redacted]. ASH’s records show that ASH reported the updated address to [redacted] on 6/17/13.

As you know, the claims impacted by this concern are claims payable by [redacted] under the network access arrangements that are supported by ASH. [redacted] must update their processing systems in order for claims under these programs to pay correctly. Claims payable by ASH have not been impacted since ASH has made the address update in ASH’s systems.

ASH is currently working with [redacted] to get the address updated in the [redacted] system as expeditiously as possible.

Should you have any further questions, please contact me directly at 800-972-4226 extension [redacted].

Sincerely,

Senior Manager, Clinical Operations

American Specialty Health

Review: In Jan 2015 my employer changed and we had to shift from [redacted] to [redacted] insurance. [redacted] insurance plan says 60 PHYSICAL THERAPIST VISITS PER YEAR PER PERSON. My son needed continuation of physical therapy in Jan 2015 to treat his elbow injury and my APPEAL for an out of network Physical therapist who he jhad been seeing since Dec 2014 ([redacted]) to be considered in-network PT was DENIED. MY sons elbow never fully healed and in July, 2015 my son's elbow injury started again with a pain of 9 out of 10. Our pediatrician once again gave us a referral to get PT, upset that we had stopped PT when it was helping. Now, American Specialty Health (ASH) refuses to cover more than 12 appointments of PT even though the pain in not fully treated (it varies from 3 to 8 depending on activity). [redacted] OUTSOURCES decisions of PT to American Specialty. ASH does not talk to customers of [redacted] after I was on hold for 30 minutes. [redacted] has created a chronic elbow injury in my son by outsourcing medical decisions to ASH instead of [redacted] doctors. Our pediatrician and physical therapist both agree to continue his PT until pain is completely gone since he is also a growing teenager, but [redacted]'s outsourced doctors are hiding as middlemen and preventing correct medical treatment which may affect a teenagers growth.Desired Settlement: Insurance should cover physical therapy as needed to support good health and growth in a teenager: even past 60 annual appointments if needed for pain-free lifestyle and healthy body.

Business

Response:

please see attached response that was sent via US mail to the complainant today. Mr. [redacted],American Specialty Health (ASH) has reviewed the complaint you submitted to the Revdex.com regarding services rendered to your son, [redacted], by [redacted]. Your complaint indicates that your son’s benefit plan allows for 60 physical therapist visits per year and that ASH refuses to cover more than 12 appointments of physical therapy. Your benefit program requires verification of medical necessity for services to be considered covered under your plan. In this case, records were submitted by [redacted] on 8/17/15 for dates of service 8/5/15 – 9/15/15 for 12 physical therapy visits. The submitted request was processed under #[redacted]. The Medical Necessity Review (MNR) Response letter sent to you and copied to [redacted] indicated that 7 dates of service with 4 units per date of service were verified as medically necessary. Under the program administered by ASH on behalf of [redacted], members can receive payment for the first five visits of the calendar year to a physical therapy services practitioner without the need for medical necessity verification. After the first five visits of the year or after a request for medical necessity verification is submitted, any other services require submission of medical records to ASH for clinical evaluation. On 8/28/15, ASH received a request for verification of medical necessity for a date range of 8/25/15 – 10/16/15 requesting 8 additional dates of service (#[redacted]). The Medical Necessity Review (MNR) Response letter sent to you and copied to [redacted] indicated that 6 dates of service with 4 units per date of service were verified as medically necessary during the date range requested. The documentation submitted indicated that the patient is functioning at a very high level including continuing to play tennis for 5 to 6 days a week for one and one half hours per day as well as conducting teaching tennis clinics. It was reported that initial complaint of pain was 8 out of 10 and had improved to mild pain level of 3 out of 10. Strength testing was reported with mild limitations of forearm musculature as 4+ to 5/5 (5/5 equals normal strength or no deficit). Ranges of motion for right forearm were reported as mildly decreased to normal ranges with some hypermobility at end range of supination and extension which could be related to younger age (bone growth not completed and increased elasticity of muscle, tendons and ligaments) or due to the continued repetitive nature of this injury. Functional Outcome Measure (FOM), DASH was reported to have improved from a score of 16.38, to 12.93, both indicating minimal disability. FOM score change was less than 4 and did not meet minimum clinically detectable change. Orthopedic stress testing for the medial ulnar collateral ligament noted intermittent mild symptoms only during periods of flare ups however no report of ligamentous laxity or a positive test on findings submitted. There was no other report of objective findings indicating that there were any other deficits in the right arm. An overall review of the clinical findings, nature and stage of the condition, as well as the repetitiveness of the injury, a total of 18 visits is more than the appropriate amount of care for this recurrent chronic condition. With the member’s ongoing high level of activity that continues to exacerbate his elbow symptoms described above, there is no indication that additional visits would resolve the mild clinical deficits or decrease his complaints of pain to 0/10.[redacted]. has the option of submitting a request to reopen the most recent medical necessity review should they have additional information to support the needed services. In addition, if future services are needed, [redacted]. can submit a new request to ASH for verification of medical necessity. You may also be able to file an appeal directly with [redacted] if you would like the denied services to be reviewed again. Please contact [redacted] directly to submit such an appeal. In response to your concern that ASH could not speak to you about your concerns, ASH is not delegated by [redacted] for the handling of member phone calls. ASH directs all member calls back to [redacted] for customer service handling. ASH apologizes for the long hold time you experienced when contacting us. We strive to provide the best possible customer service and will use your feedback to help improve our level of service. Should you have any questions, please contact me directly at [redacted] extension [redacted].Sincerely,[redacted]American Specialty Health

Consumer

Response:

The worst "insurance provider" experience by far. It verges on false advertising. They define their service to most of their paid customers/patients as 20 or 30 visits a year. Actually, the service is 5 visits (with pages of extra paperwork for patient and doctor), and then begging for any additional treatments after that. The payment to the provider is so low that it is not possible to cover minimum expenses. Getting away from them is like being caught in a repetitive loop. They can't find the paperwork. There is no one to help because you can only call one number and the same people switch you back and forth with recorded voice mails. But they don't care anyway so it's all a huge unprofessional scam. As they generate more sales with what must be low-ball pricing, and promise the moon services, the worse the situation will become. The only possibility of change will come from professionals and patients speaking up and revealing what's behind the curtain.

Review: I have submitted several health insurance claims for chiropractic services I have received from my provider to American Specialty Health over a period of 5 month. Every claim I have sent them is followed by a letter from them requesting more information. In each case I and my doctor have provided the requested information.

Claim #1 submitted for upper cervical vertebrae adjustment I received over the month of May and June 2014 was approved for reimbursement

Claim #2 submitted for upper cervical vertebrae adjustment I received over the month of July and August 2014 was DENIED

Claim #3 submitted for upper cervical vertebrae adjustment I received over the month of September was DENIED because they claim the services (upper cervical vertebrae adjustment) is not professionally recognized and is considered to be scientifically implausible. They approved me for the same exact services for the month of May and June.

Claim #4 submitted for upper cervical vertebrae adjustment I received over the month of October was 62.5% approved for reimbursement again for the same exact services they are denying for July, August, and September. How can the company approve me for upper cervical vertebrae adjustment in May and June and deny me for the same services in July, August, and September but then approve me for October. There medical decisions are not consistent. There reimbursement process is antiquated. It takes over a month to get an answer from them.Desired Settlement: I would like all of my medical claims approved for payment by my healthcare provider including payments for claims being submitted for November 2014, December 2015 and January 2015

Business

Response:

please see attached letter being placed in the mail to the copmlainant today. April 20, 2015[redacted]RE: Response to RevDex.com (Revdex.com) Complaint ID #[redacted] Ms. [redacted],American Specialty Health (ASH) has reviewed the complaint you

submitted to the Revdex.com regarding claims for services rendered to you by

chiropractor [redacted]. Your

complaint questioned the denial of claims from July, August and September,

2014. You also expressed concern that

claims for similar services had been paid in May and June, 2014, and again in

October, 2014. Your benefit program requires verification of medical necessity for

services to be considered covered under your plan, whether those services are

rendered by a participating practitioner or a non-participating practitioner. In this case, since you sought services from

a non-participating practitioner, you are responsible for ensuring that

sufficient information for verification of medical necessity has been submitted

in order to allow your claims to be processed. In this case, records were submitted on 7/31/14 for dates of service

5/31/14 – 6/28/14 for 1 new patient exam and 8 office visits. The submitted request was processed under

MNR#10500197 and reviewed for DOS 05/31/14 to 06/28/14. The Medical Necessity Review (MNR) Response

letter sent to you and copied to Dr. [redacted] indicated that 8 office visits during

that range of dates were approved and the new patient exam was denied. The new patient exam was denied because this

service had been previously submitted for payment and was a duplicate. Under the program administered by ASH on

behalf of Empire Blue Cross Blue Shield, members can receive payment for the

first five visits of the calendar year to a chiropractic practitioner without

the need for medical necessity verification.

After the first five visits of the year or after a request for medical

necessity verification is submitted, any other services require submission of

medical records to ASH for clinical evaluation. Even though these initial

office visits for these dates of service in 2014 were approved, the response

letter called attention to significant deficiencies in the documentation

submitted. For example, the MNR Response letter outlined what additional detail

would be needed should additional treatment be needed. Such information was noted as including

specific findings and clinical details within your treatment records such as

appropriately documented range of motion findings. The detail and rationale for services that

were noted in our response are necessary to verify why the particular services

requested, such as the new patient exam, were medically necessary. . On 11/11/14, an MNR form requesting DOS 07/01/14 to 08/29/14 for 1

established patient exam and 16 office visits was submitted. The submitted request was processed under

MNR#10604375. The requested services

were denied as not medically necessary and you and Dr. [redacted] were provided

detailed information regarding the rationale for this clinical denial. The denial reasons communicated included that

the range of motions findings were not clearly described so that the treatment

provided could be verified as medically necessary. Likewise, the daily chart notes did not

provide significant enough detail about your condition to verify the medical

necessity of the services rendered. ,

orthopedic testing was not performed,.

The denied services also included requests related to Thermography. The denial reasons specified that those

requests were denied because current clinical studies do not support the usefulness

of Thermography in evaluating your documented conditions, e.g., subluxations or

pain in the spine or arms and legs. On 12/23/14 an MNR form requesting DOS 09/01/14 to 09/29/14 for 1

established patient exam and 7 office visits, 1 neurological test

(electrodiagnostic surface EMG) and 1 cervical x-ray was submitted. The submitted request was processed under

MNR#[redacted]. The requested services

were clinically denied as not medically necessary. The response letter to you and Dr. [redacted] outlined

that the requested examination was denied because the submitted findings did

not meet the criteria for an examination.

The letter went on to state that the requested dates of service were

denied because the palpatory findings were not clearly described, the range of

motion findings were not clearly described, orthopedic testing was not

performed, the daily chart notes were inadequate, and the need for

electrodiagnostic testing was not supported in the medical record as there was

no documentation of a neurological examination being performed that would have

supported the need for electrodiagnostic testing. On 01/12/15 Dr. [redacted] spoke with the

clinical reviewer that had rendered this determination. The clinical reviewer discussed the case with

Dr. [redacted] and identified to him the deficiencies and inadequacies within the

medical records. He reviewed with Dr.

[redacted] the objective reporting requirements, and faxed to Dr. [redacted]

information about appropriate documentation to assist Dr. [redacted] and provide

him with a packet of forms he may use to address these concerns. The clinical reviewer also provided an

explanation on how he may submit a ReOpen form along with additional

information for reconsideration of these determinations based on that

information. On 02/10/15, a ReOpen/Modification for MNR#[redacted] was submitted for

DOS 09/01/14 to 09/29/14 for 1 established patient exam and 7 office

visits. Despite additional information

being provided, the requested services were clinically denied as not medically

necessary as the new information did not support the medical necessity of the

services performed. Specifically, a Back

Index form and a Low Back Pain and Disability Questionnaire indicating some low

back pain and some low back limitations were submitted along with a Neck Index

form that you completed. The score on

the Neck Index form was “0”, indicating no neck pain, no restrictions in

activity and the ability for you to perform normal activities without neck

pain. The notification letter included

information that clinical committees have determined adjusting the upper

cervical spine (neck area) to treat chief complaints unrelated to the cervical

spine (e.g., lumbar or lower back pain) is not established as clinically

effective, is not professionally recognized (not widely accepted and used) and

is considered to be scientifically implausible. On 12/23/14 an MNR form requesting DOS 10/02/14 to 10/27/14 for 1

established patient exam and 8 office visits was submitted. The requested services were clinically denied

as not medically necessary under MNR#[redacted].

The notification letter to you and Dr. [redacted] indicated that the

services were denied because the submitted information did not meet the

criteria for an established patient exam, the daily chart notes were inadequate

and did not provide significant details about the your condition, and that the

submitted information was generic and did not contain specific information

regarding your treatment. On 01/12/15,

Dr. [redacted] had a clinical discussion about MNR#[redacted] (involving DOS

10/02/14 to 10/27/14 for 1 established patient exam and 8 office visits) with

the clinical reviewer that reviewed the case.

During the conversation Dr. [redacted] provided additional clinical

information sufficient for this clinical review to approve five office

visits. The discussion did not provide

sufficient clinical information to approve the established patient exam or the

remaining three office visits.Based on the information above, the main cause of the discrepancy

between services being approved and being denied is related to the

documentation submitted by Dr. [redacted]. At

this time, you can work with Dr. [redacted] to obtain additional documentation to

submit to ASH for further review of medical necessity or you can file an appeal

directly with your health plan. Should you have any questions, please contact me directly at

[redacted] extension [redacted].Sincerely,[redacted]Senior Manager, Clinical OperationsAmerican Specialty Health