Golden Triangle Pharmacy Services

I believe there may be some confusion with regard to the timeliness of the refund due to the patient referenced in the above listed complaint IDWhile the patient did in fact pay $1,511,(less than quoted amount in previous), and is potentially due a refund of $144.71, the timeliness of the refund is dependent upon the receipt of payment by the insurance company for claims in full, which as of today has not occurredThe complaint letter listed that after the insurance "settled" the accounts the patient was due a refund, but I believe there may be a lack of understanding when a claim is "settled" on behalf of the provider.When medical claims are submitted to an insurance carrier, the insurance carrier has by law days from the date the claim is received to process what is called a "clean claim" meaning that all details required by the carrier or insurance company was received and the claim can be processed according to plan benefits.Once that claim is processed and at a status of paid it can take up to 7-business days to receive the check along with an explanation of benefits from the carrierBecause payments are distributed to providers for multiple patients and claims on one bulk check, the time delay in receiving that explanation of benefits usually means the patient receives their copy a considerable amount of time soonerIn this particular instance for example, a claim with a payment date of 3/3/was not received in our office by regular mail until 3/16/To date, one claim is outstanding for the above referenced ID which we are hopeful should arrive any dayWhile we do our best to collect accurately the amount a patient will potentially owe, providers cannot work on the assumption that claims will be processed and paid due to a quote of benefits given by the insurance: a quote of benefits is not a guarantee of paymentTherefore all applicable money paid toward a claim by the patient cannot be refunded until each claim is fully processed, paid, and payment is received.The patient should also reference the letter mailed by the insurance company dated 12/31/which states "Payment is based on information in the submitted claim, the actual health care services you received, and your plan benefit language and eligibility when the services are providedWe review claims submitted by providers to assure that the codes submitted are consistent with the services approved for coverageAt the time the claims are submitted, we may request medical records in order to verify that the services performed are the approved covered servicesClaim payments are based on reimbursement policies, correct coding, co-payments, co-insurance, and deductibles.We too at Golden triangle Pharmacy want to reach a desired resolution with our valued customer and have full intentions to do so by promptly issuing a refund of $as soon as payment is received for the outstanding claimWhile I can relate to the patient's frustration as dealing with insurance companies is a complicated process, I feel it was explained sufficiently by [redacted] that a refund could not be issued until all explanation of benefits and payments were receivedI cannot be certain the number of times our office was contacted with regards to the refund but I would like to make reference to the date of 3/13/as it was a Sunday and not during our working hours.I do not feel like any billing practice has been neglected or any wrongdoing has been done in the situation that should negatively affect any accreditationI think there may have been a lack of understanding the general claims process and it is my hope that this letter will help to make all parties more educated and aware of the process.Kindly, [redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 11239031, and find that this resolution is satisfactory to me
Sincerely,
*** ***

Complaint:
I am rejecting this response because:
Sincerely,
*** ***I understand what he is saying about the claim process but I actually have records from my insurance where the payment for the time period I included in my complaint has been cashed or received by Golden Triangle pharmacy This could have been addressed by *** but instead every call I made I was given the excuse that the billing manager was out, was on vacation and so fortheach time I was told by *** that I would get a call back which to this date has not happenedthe last call back was to be by Wednesday the 16th of March and I'm still waiting for that callYes thank you *** for your outstanding customer serviceIts shame when the only time a business can communicate with a customer that has called numerous times is only because of a Revdex.com complaint*** had numerous occasions to answer or have the billing manager call me but instead she shrugged me offI want to reiterate that my insurance started paying them in full in late JanuaryI just as I'm writing this response I have once again called *** *** who contradicts everything that they have responded to

I believe there may be some confusion with regard to the timeliness of the refund due to the patient referenced in the above listed complaint ID. While the patient did in fact pay $1,511,35 (.30 less than quoted amount in previous), and is potentially due a refund of $144.71, the timeliness of the...

refund is dependent upon the receipt of payment by the insurance company for claims in full, which as of today has not occurred. The complaint letter listed that after the insurance "settled" the accounts the  patient was due a refund, but I believe there may be a lack of understanding when a claim is "settled" on behalf of the provider.When medical claims are submitted to an insurance carrier, the insurance carrier has by law 45 days from the date the claim is received to process what is called a "clean claim" meaning that all details required by the carrier or insurance company was received and the claim can be processed according to plan benefits.Once that claim is processed and at a status of paid it can take up to 7-10 business days to receive the check along with an explanation of benefits from the carrier. Because payments are distributed to providers for multiple patients and claims on one bulk check, the time delay in receiving that explanation of benefits usually means the patient receives their copy a considerable amount of time sooner. In this particular instance for example, a claim with a payment date of 3/3/16 was not received in our office by regular mail until 3/16/16. To date, one claim is outstanding for the above referenced ID which we are hopeful should arrive any day. While we do our best to collect accurately the amount a patient will potentially owe, providers cannot work on the assumption that claims will be processed and paid due to a quote of benefits given by the insurance: a quote of benefits is not a guarantee  of payment. Therefore all applicable money paid toward a claim by the patient cannot be refunded until each claim is fully processed, paid, and payment is received.The patient should also reference the letter mailed by the insurance company dated 12/31/15 which states "Payment is based on information in the submitted claim, the actual health care services you received, and your plan benefit language and eligibility when the services are provided. We review claims submitted by providers to assure that the codes submitted are consistent with the services approved for coverage. At the time the claims are submitted, we may request medical records in order to verify that the services performed are the approved covered services. Claim payments are based on reimbursement policies, correct coding, co-payments, co-insurance, and deductibles.We too at Golden triangle Pharmacy want to reach a desired resolution with our valued customer and have full intentions to do so by promptly issuing a refund of $144.71 as soon as payment is received for the outstanding claim. While I can relate to the patient's frustration as dealing with insurance companies is a complicated process, I feel it was explained sufficiently by [redacted] that a refund could not be issued until all explanation of benefits and payments were received. I cannot be certain the number of times our office was contacted with regards to the refund but I would like to make reference to the date of 3/13/16 as it was a Sunday and not during our normal working hours.I do not feel like any billing practice has been neglected or any wrongdoing has been done in the situation that should negatively affect any accreditation. I think there may have been a lack of understanding the general claims process and it is my hope that this letter will help to make all parties more educated and aware of the process.Kindly,[redacted]

To Whom It May Concern:It is our sincere apology that you are not satisfied with services provided by our office. I would like to reiterate that once all of your claims were paid in full, a refund check was issued to you in the amount of $144.71 and mailed on April 8, 2016.I am uncertain of the information provided to you by [redacted] Healthcare, as I was not present for these phone calls. I can however assure you that if any billing practices on our behalf were inaccurate or erroneous we would have have been contacted by [redacted] Healthcare as we are a contracted provider and are bound by said contract to fully cooperate within certain guidelines and timeframes.I certainly hope that this letter and aforementioned refund check concludes the issue at hand. Sincerely,[redacted], Billing Representative