Essence Healthcare

After repeated inquiries to remove dental/vision addon from bill, latest statement showed the addon still there. But before that, the first time joined the HMO, member id cards showed wrong pcp. Not once but #4 times printed mistake. Billing dept needs to hire competent people. If I had to rate essence, my rating would be (0). Just for the countless typos on the bill and member cards. And when talk to a representative, requests seem to fall on deaf ears. Very incompetent reps handling call center. Might have to go back to old HMO "healthnet"

On 4/9/2018, Essence Healthcare (“Essence”) was notified by the Revdex.com of a complaint filed by [redacted] [redacted] alleged that the Plan lied to him about StFrancois County being located in the Plan’s service area [redacted] also stated that the Plan is charging him an extra $per month for his lack of credible drug coverage for months, for which he stated he should not be responsible [redacted] is moving from StLouis City to StFrancois County and when he called Essence’s Customer Service Department to notify the Plan of his address change, he was advised that StFrancois County is outside of the Plan’s service area Essence called [redacted] who indicated that he was told StFrancois County was in the Plan’s service area when he met with a Sales Agent at [redacted] *** in June Essence advised [redacted] that StFrancois County was in the service area at that time, and that StFrancois was removed from the service area on 12/31/ [redacted] was advised that he did not receive written notification that StFrancois was no longer in the Plan’s service area because these notifications were only sent to StFrancois County residents, and at the time the letters were sent, his permanent address was in StLouis City Essence spoke to [redacted] about his $monthly late enrollment penalty (LEP) for lack of credible drug coverage and explained that this penalty is assessed by Medicare, not Essence [redacted] was reminded that Essence sent him a letter on 1/16/informing him of his LEP and providing instructions on how to submit an appeal/credible coverage information, but Essence never received a response, which is why he is being charged the $LEP [redacted] understands that StFrancois County is outside of the Plan’s service area and that he will be disenrolled the first of the following month after his disenrollment is processedTell us why here

SUMMARY:Mr [redacted] , Jris unhappy about the cost of his prescriptions rising and unsatisfied with the customer service he received from Essence Health Plan (Essence)Mr [redacted] was unaware of the Medicare Part D Coverage Gap (https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html) which he is now in, resulting in higher prescription costs for himUnfortunately, Mr [redacted] signed up for a Medicare Advantage plan without any assistanceMr [redacted] didn’t enroll the help of a sales representative who would have reviewed his options with him and discussed all of the pros and cons of various health plans to assist in determining the best one for himThe sales representatives also go over all of the benefits, co-pays, deductibles, etcAs for the customer service he received from Essence, Mr [redacted] called Essence a couple of times on 5/6/and spoke to a number of Essence associatesThe calls were reviewed and the associates were trying to assist Mr [redacted] in understanding the coverage gap, and to see if he qualified for any financial assistance DETAILS:Mr [redacted] enrolled in the Essence Health Plan online without assistanceMr [redacted] saw an ad for the health plan at his provider’s office, researched to ensure his providers were in the network, and signed up for the planA sales representative contacted Mr [redacted] by phone on 8/20/to see if he had any questions about the planMr [redacted] asked if he could use [redacted] The sales representative indicated he could, but also noted that [redacted] is our preferred pharmacy and he would save money if he utilized themMr [redacted] asked if Medicare would be his primary carrier and Essence would be secondaryThe sales representative explained that Essence will be his primary insurance and handle his claims, and that Essence receives payment from Medicare to do soMr [redacted] also asked why someone would choose the Advantage Plus plan and pay a $monthly premium over a plan without a premiumThe sales representative indicated that it can reduce hospital and medical co-pays, and be beneficial for someone who takes a lot of expensive medicationThe sales representative indicated the Plus plan may benefit those who fall into the coverage gap, or donut holeMr [redacted] had no further questionsThe sales representative explained to Mr [redacted] that his Primary Care Physician (PCP) needs to submit a referral for any specialists he may need to seeMr [redacted] indicated he currently sees a cardiologist who is in the networkThe sales representative told Mr [redacted] to make sure he tells his PCP that he needs a referralThe sales representative offered to provide the customer service number and Mr [redacted] refused indicating he can look onlineThe sales representative indicated she would send her business card and he should feel free to contact her if he has any questionsOn 5/6/at 9:a.mMr [redacted] called Essence’s customer service to ask why the cost of his medication was higherThe customer service representative explained that he had reached the coverage gap, explained the coverage gap, and offered to see if he qualified for assistanceThe customer service representative transferred Mr [redacted] to someone who could determine if he qualified for assistanceOn 5/6/at 9:a.mMr [redacted] called Essence’s customer service back after it was determined that he did not qualify for financial assistanceMr [redacted] wanted additional information about the coverage gapThe customer service representative explained that there is initial prescription coverage, and once $3,has been spent on prescriptions, the coverage gap beginsOnce in the coverage gap, a beneficiary pays 58% for generic drugs in tiers and For brand name drugs in tiers 3, 4, and 5, beneficiaries receive a 55% discount off the plan allowed cost of the drugOnce a beneficiary has spent $4,out-of-pocket, he/she is out of the coverage gap and in catastrophic coverageAt that time, a beneficiary pays $for generic medications, and $or 5%, whichever is greater, for brand name medicationsOn 5/12/16, the SIU Manager contacted Mr [redacted] to verify if he had received any assistance from a sales agent, or if he attended any marketing event to obtain information about the planMr [redacted] indicated he did notThe manager asked him if he wanted someone to reach out to him to thoroughly explain the coverage gap and how it worksHe replied he would appreciate thatMr [redacted] also asked if he could change plansThe manager told him she could not answer that question but would have someone reach out to him to discussOn 5/13/16, the Lead Clinical Pharmacist spoke with Mr [redacted] He asked her to explain the donut holeShe explained the initial coverage phase, gap, and catastrophic and the dollar thresholds to move to each phaseShe explained that this is how the government set up Medicare Part D, and it is not specific to the Essence benefitMr [redacted] voiced understanding and said that prior to reaching the gap he did not understand that his cost share for drugs would go upWe discussed that he is unlikely to reach catastrophic on his current drug regimen and that he will reset to the initial coverage phase on 1/1/She suggested that he apply for the Extra Help program and MORXMr [redacted] had already applied for both and actually just found out that he qualified for MORX, so that will cut his drug costs in half We discussed patient assistance programsPradaxa PAP is not available to Medicare Part D membersMedicare Part D members can qualify for the Lantus PAP in certain circumstances; she asked him if he wanted her to send a printed application and he said he would fill it out onlineThey also discussed that there is a lower cost insulin, Relion, but that it would require dose adjustment if his doctor switched

A member needing urgent care or emergency care while out of his/her service area may be seen by any facility that accepts MedicareEssence Customer Service hours are currently Monday – Friday, a.mthrough p.mIf a member calls outside of these hours, he/she may leave a voicemail message which will be returned the following business dayMr [redacted] did leave a voicemail message, and his call was returnedThe Customer Service Representative explained to Mr [redacted] that providers who accept Medicare should treat him and bill Essence; however, if the provider would not bill us, Mr [redacted] could pay out of pocket and submit the receipt for reimbursement

Ms*** *** stated that Essence Healthcare (Essence) denied her 9/6/medical claim and is unwilling to provide her with an explanation of the denial reasonCompliance contacted Ms*** by phone to discuss her concernMs*** advised that on 9/6/16, she attended a medical
appointment with Dr*** *** and presented her Medicare card for proof of insuranceMs*** stated that she received notification from Dr***’s office that her 9/6/medical claim was denied by MedicareCompliance advised the beneficiary that her medical claim history with Essence does not reflect a 9/6/medical claim from Dr*** and that she would need to provide Dr***’s office with her Essence insurance information in order for her office to bill EssenceCompliance informed Ms*** that Essence is her Medicare replacement and she should only provide her Essence card during medical appointments and at the pharmacyIn addition, Compliance explained to Ms*** that once the claim is received and processed by Essence, she will be notified in the mail by an Explanation of Benefits (EOB) statement on whether the claim was approved or denied by EssenceFurthermore, Ms*** was advised that if the claim is denied for payment, the EOB will provide a detailed explanation of the denial reason with her appeal rights, and phone number for Essence Customer Service so she can speak with an Essence representative regarding any further questionsMs*** advised she understood this information and would contact Dr***’s office to provide her staff with her Essence insurance information
On 10/4/16, Essence received Ms***’s 9/6/office visit medical claim from Dr***’s office. The claim is currently being processed by Essence according to the medical claim timelines

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me
Sincerely,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me
Sincerely,
*** ***

Essence Healthcare, Inc. (Essence) received notification on 1/24/2017 from the Revdex.com regarding a complaint filed by Essence beneficiary, [redacted]. Mr. [redacted] wrote the following: I am writing to request an appeal of denial of payment for medical services provided by...

[redacted] on 4/5/2016. I was treated by Dr. [redacted] at an Urgent Care facility in [redacted], Florida while on vacation. The reason listed in Notice of Denial of Payment is "pre-approval was not obtained." A review of Mr. [redacted]’s claim history identified that the claim submitted by Dr. [redacted] for date of service 4/5/2016 was originally denied on 5/20/2016 because pre-approval was not obtained and there was no indication on the claim that it related to urgent or emergent care, which is covered by the Plan even if outside the service area or obtained by a non-contracted provider. Further review identified the claim from Dr. [redacted] was later identified as related to an urgent care visit and the claim was reprocessed and paid on 8/12/2016.   Essence reviewed all of the documents submitted by Mr. [redacted], and it appears there is one bill for date of service 4/5/2016 that was not paid. The services billed by [redacted] Memorial Hospital for the Urgent Care visit totaled $215.00. Mr. [redacted] paid $45 at the time of service, thus leaving a balance of $170.00. We believe Mr. [redacted]’s concern is this bill since it was sent to collections and he paid for the services.  A claim was submitted by [redacted] Memorial Hospital and rejected on 5/13/2016 because it was billed without the required HCPCS codes. The hospital never submitted a corrected bill. Instead, the hospital billed Mr. [redacted] and eventually sent the bill to a collection agency. Essence has attempted to contact Mr. [redacted] to discuss this matter, and has left voicemail messages for him, but to date, our calls have not been returned. The claim from [redacted] Memorial Hospital has been sent to the Appeals Department for review.  Essence believes this claim is payable by the Plan under its stated benefits, but requires either resubmission of the claim by the hospital or Mr. [redacted], or a request for direct reimbursement from Mr. [redacted].  Essence will continue to outreach to Mr. [redacted] and the hospital to resolve the matter to his satisfaction.

A member needing urgent care or emergency care while out of his/her service area may be seen by any facility that accepts Medicare. Essence Customer Service hours are currently Monday – Friday, 8 a.m. through 8 p.m. If a member calls outside of these hours, he/she may leave a voicemail...

message which will be returned the following business day. Mr. [redacted] did leave a voicemail message, and his call was returned. The Customer Service Representative explained to Mr. [redacted] that providers who accept Medicare should treat him and bill Essence; however, if the provider would not bill us, Mr. [redacted] could pay out of pocket and submit the receipt for reimbursement.

On 4/9/2018, Essence Healthcare (“Essence”) was notified by the Revdex.com of a complaint filed by [redacted].  [redacted] alleged that the Plan lied to him about St. Francois County being located in the Plan’s service area.  [redacted] also stated that the Plan is...

charging him an extra $27 per month for his lack of credible drug coverage for 77 months, for which he stated he should not be responsible [redacted] is moving from St. Louis City to St. Francois County and when he called Essence’s Customer Service Department to notify the Plan of his address change, he was advised that St. Francois County is outside of the Plan’s service area.  Essence called [redacted] who indicated that he was told St. Francois County was in the Plan’s service area when he met with a Sales Agent at [redacted] in June 2016.  Essence advised [redacted] that St. Francois County was in the service area at that time, and that St. Francois was removed from the service area on 12/31/2017.  [redacted] was advised that he did not receive written notification that St. Francois was no longer in the Plan’s service area because these notifications were only sent to St. Francois County residents, and at the time the letters were sent, his permanent address was in St. Louis City.  Essence spoke to [redacted] about his $27 monthly late enrollment penalty (LEP) for lack of credible drug coverage and explained that this penalty is assessed by Medicare, not Essence.  [redacted] was reminded that Essence sent him a letter on 1/16/2018 informing him of his LEP and providing instructions on how to submit an appeal/credible coverage information, but Essence never received a response, which is why he is being charged the $27 LEP. [redacted] understands that St. Francois County is outside of the Plan’s service area and that he will be disenrolled the first of the following month after his disenrollment is processed. Tell us why here...

SUMMARY:Mr. [redacted], Jr. is unhappy about the cost of his prescriptions rising and unsatisfied with the customer service he received from Essence Health Plan (Essence). Mr. [redacted] was unaware of the Medicare Part D Coverage Gap...

(https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html) which he is now in, resulting in higher prescription costs for him. Unfortunately, Mr. [redacted] signed up for a Medicare Advantage plan without any assistance. Mr. [redacted] didn’t enroll the help of a sales representative who would have reviewed his options with him and discussed all of the pros and cons of various health plans to assist in determining the best one for him. The sales representatives also go over all of the benefits, co-pays, deductibles, etc. As for the customer service he received from Essence, Mr. [redacted] called Essence a couple of times on 5/6/16 and spoke to a number of Essence associates. The calls were reviewed and the associates were trying to assist Mr. [redacted] in understanding the coverage gap, and to see if he qualified for any financial assistance.  DETAILS:Mr. [redacted] enrolled in the Essence Health Plan online without assistance. Mr. [redacted] saw an ad for the health plan at his provider’s office, researched to ensure his providers were in the network, and signed up for the plan. A sales representative contacted Mr. [redacted] by phone on 8/20/15 to see if he had any questions about the plan. Mr. [redacted] asked if he could use [redacted]. The sales representative indicated he could, but also noted that [redacted] is our preferred pharmacy and he would save money if he utilized them. Mr. [redacted] asked if Medicare would be his primary carrier and Essence would be secondary. The sales representative explained that Essence will be his primary insurance and handle his claims, and that Essence receives payment from Medicare to do so. Mr. [redacted] also asked why someone would choose the Advantage Plus plan and pay a $79 monthly premium over a plan without a premium. The sales representative indicated that it can reduce hospital and medical co-pays, and be beneficial for someone who takes a lot of expensive medication. The sales representative indicated the Plus plan may benefit those who fall into the coverage gap, or donut hole. Mr. [redacted] had no further questions. The sales representative explained to Mr. [redacted] that his Primary Care Physician (PCP) needs to submit a referral for any specialists he may need to see. Mr. [redacted] indicated he currently sees a cardiologist who is in the network. The sales representative told Mr. [redacted] to make sure he tells his PCP that he needs a referral. The sales representative offered to provide the customer service number and Mr. [redacted] refused indicating he can look online. The sales representative indicated she would send her business card and he should feel free to contact her if he has any questions. On 5/6/16 at 9:02 a.m. Mr. [redacted] called Essence’s customer service to ask why the cost of his medication was higher. The customer service representative explained that he had reached the coverage gap, explained the coverage gap, and offered to see if he qualified for assistance. The customer service representative transferred Mr. [redacted] to someone who could determine if he qualified for assistance. On 5/6/16 at 9:16 a.m. Mr. [redacted] called Essence’s customer service back after it was determined that he did not qualify for financial assistance. Mr. [redacted] wanted additional information about the coverage gap. The customer service representative explained that there is initial prescription coverage, and once $3,310.00 has been spent on prescriptions, the coverage gap begins. Once in the coverage gap, a beneficiary pays 58% for generic drugs in tiers 1 and 2. For brand name drugs in tiers 3, 4, and 5, beneficiaries receive a 55% discount off the plan allowed cost of the drug. Once a beneficiary has spent $4,850.00 out-of-pocket, he/she is out of the coverage gap and in catastrophic coverage. At that time, a beneficiary pays $6.95 for generic medications, and $7.90 or 5%, whichever is greater, for brand name medications. On 5/12/16, the SIU Manager contacted Mr. [redacted] to verify if he had received any assistance from a sales agent, or if he attended any marketing event to obtain information about the plan. Mr. [redacted] indicated he did not. The manager asked him if he wanted someone to reach out to him to thoroughly explain the coverage gap and how it works. He replied he would appreciate that. Mr. [redacted] also asked if he could change plans. The manager told him she could not answer that question but would have someone reach out to him to discuss. On 5/13/16, the Lead Clinical Pharmacist spoke with Mr. [redacted]. He asked her to explain the donut hole. She explained the initial coverage phase, gap, and catastrophic and the dollar thresholds to move to each phase. She explained that this is how the government set up Medicare Part D, and it is not specific to the Essence benefit. Mr. [redacted] voiced understanding and said that prior to reaching the gap he did not understand that his cost share for drugs would go up. We discussed that he is unlikely to reach catastrophic on his current drug regimen and that he will reset to the initial coverage phase on 1/1/17. She suggested that he apply for the Extra Help program and MORX. Mr. [redacted] had already applied for both and actually just found out that he qualified for MORX, so that will cut his drug costs in half.  We discussed patient assistance programs. Pradaxa PAP is not available to Medicare Part D members. Medicare Part D members can qualify for the Lantus PAP in certain circumstances; she asked him if he wanted her to send a printed application and he said he would fill it out online. They also discussed that there is a lower cost insulin, Relion, but that it would require dose adjustment if his doctor switched.