Aspire Urgent Care and Family Medicine

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: [redacted] I am rejecting this response because: [1] A referral is not required for urgent care, like the kind you get from an emergency room [2] My wife called ahead to confirm that we would be seen as urgent care, not regular office visit We were told over the phone that this would be the case Otherwise we would have visited the Emergency Room at the Hospital [3] After we received the bill and contacted Aspire to find that we needed the referral, we did in fact send the referral to Aspire, twice, from different doctor’s offices(Twice) [4] We were not instructed by Aspire to call [redacted] after we received the referral to ask [redacted] to reprocess the claim Our PCP contacted [redacted] to get the referralOnce Aspire had the [redacted] referral, Aspire should have processed the claim [5] We did contact Aspire after 4/7/(See #3) We sent the referral to them twice, from different Doctor’s offices [6] I was NOT contacted, nor did I receive a message on 7/31/ This statement contradicts itself; if I was contacted, there would be no need to leave a message, they would just tell me [7] Of course Aspire didn’t receive payment from our insurance, they say right in their response that they were expecting me, the patient, to submit a claim I have never visited a medical office and been expected to be the one submitting the insurance claim Getting my signature stating my responsibility to pay for any amount not paid for by insurance does NOT relieve Aspire of their responsibility to submit a claim to said insurance company [8] The bill should never have gone to collections without contacting me first A “message” is NOT contacting me Who was the message left with? Regards, [redacted]

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because:
[1] A referral is not required
for urgent care, like the kind you get from an emergency room.
[2] My wife called ahead to confirm that we would be seen as urgent
care, not regular office visit.  We were
told over the phone that this would be the case.  Otherwise we would have visited the Emergency
Room at the Hospital.
[3] After we received the bill and contacted Aspire to find that we
needed the referral, we did in fact send the referral to Aspire, twice, from 2
different doctor’s offices. (Twice)
[4] We were not instructed by Aspire to call [redacted] after we received the
referral to ask [redacted] to reprocess the claim. 
Our PCP contacted [redacted] to get the referral. Once Aspire had the [redacted] referral, Aspire should
have processed the claim.
[5] We did contact Aspire after 4/7/14. (See #3) We sent the referral
to them twice, from 2 different Doctor’s offices.
[6] I was NOT contacted, nor did I receive a message on 7/31/14.  This statement contradicts itself; if I was
contacted, there would be no need to leave a message, they would just tell me.
[7] Of course Aspire didn’t receive payment from our insurance, they
say right in their response that they were expecting me, the patient, to submit
a claim.  I have never visited a medical
office and been expected to be the one submitting the insurance claim.   Getting my signature stating my
responsibility to pay for any amount not paid for by insurance does NOT relieve
Aspire of their responsibility to submit a claim to said insurance company.
[8] The bill should never have gone to collections without contacting
me first.  A “message” is NOT contacting
me.  Who was the message left with?
 
Regards,
[redacted]

March 13, 2015
[redacted]
We do indeed accept this patient's insurance. As he has an HMO, a referral from his PCP is required for services to be covered in full. Patient should be well-aware of this referral requirement. Patient was seen on 1/26/2014 and was sent billing...

statements from our office on 2/19/2014 and 3/19/2014 stating “Additional information needed to process claim. Please contact your insurance.” Per our notes, the patient contacted us on 4/7/2014 questioning why he had been receiving bills. We advised the patient that his insurance did not have a referral on file for this date of service, and reminded him of the necessity for a referral. We instructed the patient to contact his PCP and to request that his PCP send a referral to [redacted] for the date of service in question. We also instructed the patient to call [redacted] after this had been completed to ask [redacted] to reprocess the claim. Finally, we asked the patient to contact us once these items had been completed to keep us advised of the situation.The patient did not contact us after the phone call on 4/7/2014. We sent an additional statement on 4/16/2014 indicating the account was past due.We received no payment from the insurance or from the patient for the date of service in question, and on 7/31/2014, we contacted the patient and left him a message to contact us back. The message we left simply indicated we wished to speak with him. Our call was not returned. On 8/12/2014, we submittedthis patient to [redacted], the collection agency our office works with. [redacted], patient was sent a letter stating he had 30 days to clear up the balance before the patient would be credit reported.We received notification from [redacted] on our invoice dated 11/30/2014 that patient had paid in full to [redacted], and updated the patient’s account with our system accordingly,Unfortunately, this situation could have been resolved had the patient kept in communication with us. At the time of service, patient signed our Financial Policy indicating he would be responsible for any amounts his insurance did not pay. As we received no updates from the patient, and the patient was responsible for the referral at time of service, we are unable to refund the patient for services rendered that were not paid for by the patient's insurance.Copies of the statements sent to the patient mentioned above and a copy of the Financial Policy signed by the patient are included with this letter.L. J[redacted], Billing Manager
AspireCare

The additional concerns the patient has expressed were, in part, addressed by our previous response, Some information being provided in this response is a repeat of data in an attempt to address each concern. The previous response constituted the sum total of all conversations we have on record with this patient.The first concern about a referral not being required for Urgent Care is specific to the patient's plan, it is possible that Urgent Care visits do not typically require a referral for this patient's plan. However, as our contract with [redacted] requires that we bill as Family Medicine due to the dual nature of our practice, referrals are required for some patients being seen in our Urgent Care. We Sent the patient two statements without response on 2/19/14 and 3/19/14, indicating there was a problem with the claim (statements explicitly read “Additional Information Needed please contact your insurance"), and that it remained unpaid. The patient's call to us on 4/7/14 indicated he was unaware of a referral requirement – had the patient contacted his insurance as instructed on the statements, he would have been aware of the referral issue inhibiting his insurance from paying his claim, and the issue at hand could have been addressed much earlier.We cannot attest to the specifics of the conversation had with the patient's wife before the visit in question. If she called in and asked if we participate with [redacted] the answer would have been “yes”. If it was something more involved she would have been directed to speak to the billing department, or the patient would have been asked to bring in the card so that we might be able to contact their insurance directly to help with any additional questions. It's ultimately the patient’s responsibility to respond in a timely manner to statements.The patient’s third through fifth concerns with regards to communication and referrals appear to indicate that the patient contacted us immediately upon receiving our statement. That is not the case. We sent the patient statements on 2/19/14 and on 3/19/14, and received no calls from the patient until 4/7/14. Our notation of the call, which was entered into our system at 10:01am on 4/7/14, states the following, verbatim: “...instructed patient to contact his PCP and request that they send a referral for D[ate]O[f]Service] to [redacted]. After that has been completed, told patient to contact [redacted] and ask them to reprocess the claim. Finally, asked that he call us to let us know when this has been completed. Patient expressed understanding.” At no point did we instruct the patient to send any referrals to Aspire. Aspire is unable to directly process referrals for Urgent Care patients. We have no record of any referrals being received from the patient or the patient's PCP. We contacted the patient's PCP in an attempt to investigate how and when these referrals were transmitted to our office. Per the patient's PCP, no request for referral was submitted to the referral specialist. The referral specialist stated that it was possible that the request was made and it did not get passed to the correct person, but at this time, they have no record of any referrals being processed for this patient for this date of service. The patient’s statement on his previous complaint that his wife sent us a referral as well appears inaccurate, as per the patient’s PCP, all referrals for [redacted] are done electronically, with no paper referral being generated. As the PCP's office has no record of any referrals being generated for this date of service, and we have no record of having received any referrals by any source, it is unclear how this referral was submitted to us by the patient's wife.The patient's fourth concern states "once Aspire had the [redacted] referral, Aspire should have processed the claim". This concern indicates a misunderstanding of the insurance filing and referrals processes.Aspire is not an insurance company, and therefore cannot process claims. Referrals must be submitted from the PCP directly to the insurance company, at which point the insurance company will reprocess the claim. As noted previously, we instructed the patient that his PCP must send a referral to [redacted]. As cited above, per our conversation with the patient's PCP, no referrals were generated.Regarding the patient’s sixth and eighth concerns, we noted that a message was left for the patient to call back. It was left on an answering machine or voicemail, not with a person; referring to this as “contact” in our previous response was misleading.The patient's seventh concern states that his insurance informed him he was expected to submit a claim. The only instruction we received from the patient’s insurance was regarding a referral – a claim was submitted electronically by our office to the patient's insurance on the patient’s behalf on 1/29/14, thus generating the denial on the basis of the missing referral. Without a claim already on file, the missing referral would not have come to our attention. We state in our financial policy that we will submit claims on behalf of the patient. We have at no time represented that the financial policy relieves us of our responsibility to submit a claim.The patient's final concern, regarding being sent to collections without being contacted, is an unfortunate result of the patient not responding to our message on 7/31/14, Our financial policy clearly states that accounts over 90 days past due will be sent to an outside collection agency. Further, the patient did not keep in communication with us as he indicated he would in our conversation dated 4/7/14. An additional statement was sent after that conversation indicating we still had not been able to resolve this issue. It is ultimately the patient's responsibility to obtain referrals – it appears clear that the patient contacted his PCP to get this referral generated, but this was done, at minimum, six weeks after the first statement, per the patient's insistence that until the conversation on 4/7/14, he did not even know a referral was required. This period of elapsed time reduced the period of time our office had to help the patient resolve the situation before his account was sent to collections. Had the patient kept in direct communication with us after 4/7/14, the issue of Aspire having not received the promised referrals would have been exposed, and we would still have had time to work with the patient to attempt to resolve this situation before the account was sent to the collection agency.We regret that this patient encountered these issues in relation to his visit to our practice. At this time, we have contacted the patient's PCP in an attempt to obtain a back-dated referral, but were unable to obtain one due to the length of time which has elapsed from the patient's original visit. Per the suggestion of the insurance representative, we will be filing a reconsideration due to the emergency circumstances of the visit. However, based on the time elapsed from the visit, this will likely be denied, as the appeal period for this insurance is only 180 days.Regards,L. J[redacted], Billing Manager