Blue Ridge Optometry

It has come to our attention you filed a complaint against us with the Revdex.com specifically pertaining to a billing issue/dispute.  Upon reviewing your records, the manner in which you and your insurance were billed, and the steps our office took to assist, I wanted to take a...

moment to explain how we have arrived at this point.  There are no laws or regulations requiring medical providers to check our patients’ insurance eligibility to determine if the provider is in or out of network and the charges the responsible party (typically the patient) can expect to pay.  There are a number of reasons for this including and not limited to the fact that there are an enormous number of insurance plans available to patients, and whether or not a service rendered can/will be covered is dependent upon a number of factors.  However, as a courtesy to our patients we utilize an insurance eligibility tool to check and see if we are “In or Out-of-Network”.  The tool we use happens to be one of the most popular and widely used tools within optometry and ophthalmology.  Utilizing this tool, we were informed yes, we are part of your insurer’s network.  Though we are “In-Network” with [redacted], we are not part of your group.  Each insurance company has a plethora of plans offered to their clients.  Each plan is then broken into groups, and each group then chooses which providers it will service, what type of coverage will be provided to the patient, and finally what the deductible will be based on to meet the needs and the desires of the patient.  What this all means is a medical provider can be considered “In-Network” with an insurance company, yet “Out-of-Network” for a particular group within the insurance company.  When we checked with your insurance company utilizing our insurance verification tool, we were correctly informed our practice is in fact “In-Network”.  After your exam, when the bill was sent to your insurance company, with the appropriate procedure/medical billing codes, we were informed the $80.00 paid would be applied to your deductible, however we were privy tothe remaining balance of $105.00 since your deductible was not met at the time of service.  In summary, Blue Ridge Optometry is “In-Network” with [redacted], and has been for some time.  However, we are not part of your chosen group which is part of the plan you chose to participate in when you signed up with [redacted].  Likewise, at the time of service your deductible, which was negotiated and agreed upon between you and [redacted] was not met preventing [redacted] for financially covering more of the services rendered by myself and my staff during your office visit.Based on your Desired Settlement as stated on your Revdex.com Complaint we have decided to do the following.  1. We will write off the remaining balance on your account of $105.00 which is the disputed amount we are owed.  Therefore, your remaining balance will be $0.00 should you accept this settlement and our explanation above.  2. We will continue telling patients and the community we are part of the [redacted] network because we are.  There are select group plans within [redacted] we do not participate within, which is what occurred in your case, but that does not mean we do not participate with [redacted] as described above.  3. Staff will be informed at our next staff meeting to inform patients who ask if we accept their insurance, especially new patients, that it is the patient’s responsibility to check with their insurer to find out if we are part of their network.  Likewise we can provide a courtesy check for our patients, however it is in no way 100% accurate and the only way to ensure 100% accuracy is for the patient, or a representative of the patient, to call and ask their insurer directly.  4. At this point I believe it would be mutually beneficial to terminate the doctor/patient relationship so you may locate a new Optometrist who is within your specific network and can provide the service you desire.  I hope you find our explanation and resolution/settlement satisfactory. Sincerely, Scott R. Brandau, O.D.

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me.  I will wait for the business to perform this action and, if it does, will consider this complaint resolved.However, I would note that this situation had nothing to do with my deductible.  The money I paid was the office visit charge ($40 per visit) for an in-network visit.  It was not posted against my deductible with [redacted].
Regards,
[redacted]