Carolina Roof and Restoration, Inc.

2/23/16Dear *** ***, I am writing in response to Complaint ***This matter concerns the differentiation of routine eye examination from problem-based eye examination. insurance companies issue Vision Plans as a means of lowering their costs for
uncomplicated vision issuesThere are specific guidelines regarding what is considered routine versus problem-basedIn order for an evaluation to be considered routine, the patient must not offer any ocular or visual complaints to the evaluating physicianThis can be a source of confusion to many patients. As a matter of background, I have practiced Comprehensive Ophthalmology for over years I am entirely versed in billing for my specialtyNo insurance company has ever cited me for fraudulent or faulty billing practices.The patient in question came to my office as a new patient on 12/2/ He presented a medical insurance card with a $specialist copay charge printed on the face As a rule, all copays are collected prior to the examThe patient never mentioned that he had a Vision Plan at that time or any time since.In the examination room, the patient reported to me that his vision was "not crisp" when watching TV driving and other activities over the last monthsThis was an apparent change in his vision and obviously a complaintThere is a vast array of eye disease that could account for vision that is "not crisp'' ranging from dry eyes, corneal warpage from a poor contact lens fit, cataracts, brain tumors, retinal disease, etcOnce a physician is confronted with a complaint, that physician has a legal and ethical obligation to evaluation the patient to identify any vision or life threatening conditionIt is understood that the physician will undertake whatever reasonable testing is needed to identify the cause of the problem.The patient in question received a comprehensive evaluation of his visual system including a refraction for new glasses and contactsThe patient also received a set of trial contacts at no chargeIt was explained to the patient that the contacts were merely trial lenses that he may or may not opt to order through my office.Because the patient had visual complaints and because he never indicated that he had a Vision Plan, a new patient, problem based medical claim was submitted to his insurance company as well as a claim for the refraction, The claims submitted were entirely legitimate and a reflection of the nearly one hour long evaluationMy interaction with the patient was entirely cordial and professional throughout.The first indication of any problem occurred when a statement was sent to the patient for the refraction fee which was not covered by the insurance Again, the patient never indicated at any time before during or after his appointment that he had a Vision Plan In general, only one insurance, vision or medical, can be billed for any evaluation but not both.I spoke with the complainant when she called my officeShe stated that the exam was routineWhen I tried to explain that the patient had visual complaints which made his evaluation medical and not routine, she accused me of interrupting herI then listened to what she had to say and then I told her the charges and billing were correct and would not be changed.The complainant was not the patient The complainant was not present at the time of :he medical interview and to my awareness she has no knowledge or professional experience with medical billingNeither she nor the patient ever provided any information regarding Vision Plan coverageHad I been notified of a vision plan I would have explained at that time that vision complaints are not covered by Vision Plans.Last week, in an attempt to reconcile the situation, I called the patient I explained the medical billing particulars to himI told him I would waive the refraction fee of $35.00 and I apologized for any affronts his fiance perceived when I spoke to her on the phone This call took place before I received the Revdex.com complaint.Earlier today, I sent an email to the patient indicating that the Revdex.com complaint would have to be withdrawn to waive the $feeThe patient told me he also wanted $copay returned in order to withdraw the complaint and I told him this was not justified We agreed that he would have a final answer back to me by PM today and I have not heard back from him at PM this evening In summary, the patient was properly, expertly and professionally evaluated for the visual complaint he reported during the medical interviewThis information is available in the medical record The medical billing for the evaluation was accurate and legitimateThe patient never provided any information regarding any Vision Plan It is the evaluating physician who determines, based on an interview with the patient whether the exam is routine or problem-basedIt is not up to the patient or his fiance to decide that an exam is routine once they have undergone a comprehensive evaluation and have been reassured that everything is normalThe patient is still responsible for payment of the $refraction fee.Please contact me if I can provide any further information regarding this matter. Sincerely,DrMichele P***

[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: ***
I am rejecting this response because:While my complaint does describe an insurance issue, I clearly state that the root of my complaint lies with the unprofessional manner in which DrP*** spoke to me on the phoneI did not ask for a novel on insurance claims or a resume of qualifications, I simply stated my opinion that a medical professional should not speak to their patients or patients' loved ones the way I was spoken toI did not say anything or act in a way that warranted her attitude toward meShe falsely claims in her response that she apologized for her behaviorI have not received an apology, nor has ***We do not care to hear a forced apology at this point, we just want other prospective patients to be aware of our experience before choosing to see DrP*** for their eye care needsDrP*** has been personally notified by myself via email that her $charge is being paid- an extra $in my pocket would not help change the fact that she was rude when she had no reason to be
Regards,
*** ***

[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: ***
I am rejecting this response because:While my complaint does describe an insurance issue, I clearly state that the root of my complaint lies with the unprofessional manner in which DrP*** spoke to me on the phoneI did not ask for a novel on insurance claims or a resume of qualifications, I simply stated my opinion that a medical professional should not speak to their patients or patients' loved ones the way I was spoken toI did not say anything or act in a way that warranted her attitude toward meShe falsely claims in her response that she apologized for her behaviorI have not received an apology, nor has ***We do not care to hear a forced apology at this point, we just want other prospective patients to be aware of our experience before choosing to see DrP*** for their eye care needsDrP*** has been personally notified by myself via email that her $charge is being paid- an extra $in my pocket would not help change the fact that she was rude when she had no reason to be
Regards,
*** ***

2/23/16Dear *** ***, I am writing in response to Complaint ***This matter concerns the differentiation of routine eye examination from problem-based eye examination. insurance companies issue Vision Plans as a means of lowering their costs for
uncomplicated vision issuesThere are specific guidelines regarding what is considered routine versus problem-basedIn order for an evaluation to be considered routine, the patient must not offer any ocular or visual complaints to the evaluating physicianThis can be a source of confusion to many patients. As a matter of background, I have practiced Comprehensive Ophthalmology for over years I am entirely versed in billing for my specialtyNo insurance company has ever cited me for fraudulent or faulty billing practices.The patient in question came to my office as a new patient on 12/2/ He presented a medical insurance card with a $specialist copay charge printed on the face As a rule, all copays are collected prior to the examThe patient never mentioned that he had a Vision Plan at that time or any time since.In the examination room, the patient reported to me that his vision was "not crisp" when watching TV driving and other activities over the last monthsThis was an apparent change in his vision and obviously a complaintThere is a vast array of eye disease that could account for vision that is "not crisp'' ranging from dry eyes, corneal warpage from a poor contact lens fit, cataracts, brain tumors, retinal disease, etcOnce a physician is confronted with a complaint, that physician has a legal and ethical obligation to evaluation the patient to identify any vision or life threatening conditionIt is understood that the physician will undertake whatever reasonable testing is needed to identify the cause of the problem.The patient in question received a comprehensive evaluation of his visual system including a refraction for new glasses and contactsThe patient also received a set of trial contacts at no chargeIt was explained to the patient that the contacts were merely trial lenses that he may or may not opt to order through my office.Because the patient had visual complaints and because he never indicated that he had a Vision Plan, a new patient, problem based medical claim was submitted to his insurance company as well as a claim for the refraction, The claims submitted were entirely legitimate and a reflection of the nearly one hour long evaluationMy interaction with the patient was entirely cordial and professional throughout.The first indication of any problem occurred when a statement was sent to the patient for the refraction fee which was not covered by the insurance Again, the patient never indicated at any time before during or after his appointment that he had a Vision Plan In general, only one insurance, vision or medical, can be billed for any evaluation but not both.I spoke with the complainant when she called my officeShe stated that the exam was routineWhen I tried to explain that the patient had visual complaints which made his evaluation medical and not routine, she accused me of interrupting herI then listened to what she had to say and then I told her the charges and billing were correct and would not be changed.The complainant was not the patient The complainant was not present at the time of :he medical interview and to my awareness she has no knowledge or professional experience with medical billingNeither she nor the patient ever provided any information regarding Vision Plan coverageHad I been notified of a vision plan I would have explained at that time that vision complaints are not covered by Vision Plans.Last week, in an attempt to reconcile the situation, I called the patient I explained the medical billing particulars to himI told him I would waive the refraction fee of $35.00 and I apologized for any affronts his fiance perceived when I spoke to her on the phone This call took place before I received the Revdex.com complaint.Earlier today, I sent an email to the patient indicating that the Revdex.com complaint would have to be withdrawn to waive the $feeThe patient told me he also wanted $copay returned in order to withdraw the complaint and I told him this was not justified We agreed that he would have a final answer back to me by PM today and I have not heard back from him at PM this evening In summary, the patient was properly, expertly and professionally evaluated for the visual complaint he reported during the medical interviewThis information is available in the medical record The medical billing for the evaluation was accurate and legitimateThe patient never provided any information regarding any Vision Plan It is the evaluating physician who determines, based on an interview with the patient whether the exam is routine or problem-basedIt is not up to the patient or his fiance to decide that an exam is routine once they have undergone a comprehensive evaluation and have been reassured that everything is normalThe patient is still responsible for payment of the $refraction fee.Please contact me if I can provide any further information regarding this matter. Sincerely,DrMichele P***

3/4/2016Dear *** ***,This will be my final response regarding this unfortunate matterI am very sorry that the Complainant "rejects" my response to her complaintHer interpretation of "unprofessional manner" and any "rudeness" is simply her interpretationIn my view, my tone was matter of factI simply told her that the patient's exam was not, as she stated, routineYou know the facts from my previous letter.In fact, the patient came into my office not knowing about recent changes in his insuranceNeither he nor the complainant had any understanding of the differentiation of medical versus routine examsThis basic lack of understanding led the events that followed.The patient told me the complainant was "irate" over our phone conversation.Indeed, I spoke to an irate individual who would not have been happy with any response I gave herI apologized to the patient when I spoke with him on the phoneSpecifically, I said, "I apologize for any affront that was perceived."My office is highly regarded for the quality of medical care provided and the professionalismThis complaint is an outlierFor those who may view the remarks, I hope the lesson taken is that many problems arise when they are not familiar with the details of their insurance plans.Thank you for your time and interest.Kind regards,Michele PMD

3/4/2016Dear [redacted],This will be my final response regarding this unfortunate matter. I am very sorry that the Complainant "rejects" my response to her complaint. Her interpretation of "unprofessional manner" and any "rudeness" is simply her interpretation. In my view, my tone was matter of fact. I simply told her that the patient's exam was not, as she stated, routine. You know the facts from my previous letter.In fact, the patient came into my office not knowing about recent changes in his insurance. Neither he nor the complainant had any understanding of the differentiation of medical versus routine exams. This basic lack of understanding led the events that followed.The patient told me the complainant was "irate" over our phone conversation.Indeed, I spoke to an irate individual who would not have been happy with any response I gave her. I apologized to the patient when I spoke with him on the phone. Specifically, I said, "I apologize for any affront that was perceived."My office is highly regarded for the quality of medical care provided and the professionalism. This complaint is an outlier. For those who may view the remarks, I hope the lesson taken is that many problems arise when they are not familiar with the details of their insurance plans.Thank you for your time and interest.Kind regards,Michele P. MD