11-20-17RE: Case ID #12499693To whom it may concern,We received the correspondence regarding the complaint from our patient, who will be referred to as the "client" in this letterIn order to address the concerns In this complaint, I would like to demonstrate and outline for you that Certus
DentalCare, LLC does have policies and workflows in' place to educate patients regarding financial expectations and to submit and process claims in a standardized manner with accordance to insurance guidelinesEach patient signs a financial policy that addresses that our office will submit claims as a courtesy to our patients which this client did sign (attached)Next, our insurance verification specialist checks the chart prior to each visit and contacts our contracted Insurance companies to verify eligibility prior to each appointment, which was verified with United Concordia prior to the client's visitSubsequently, if a patient requires dental work, a good faith estimate is provided to the patient that outlines what the patient may owe in terms of a copay for their services based upon the most recent fees the insurance agency has provided us, what we can see in the insurance company's data base at that time regarding what claims have been submitted/processed in relation to their copays, deductibles and maximum reached, as well as their eligibilityAli this information changes frequently as claims are posted to their website, fees are updated and members eligibility changesTherefore, we tell patients (and it is written on the estimate sheet) that only after the insurance processes the claim will we know for sure how much they oweTypically our office estimates are fairly accurate for this system to be of benefit to our patientsThe estimate presented to the patient shows what insurances we are planning to submit to as per the information we have on file for the patient (which was presented to the client)Also the workflow is to submit the claim to the insurance company on the patients behalf and the insurance company then submits a check to the practice (either Certus DentalCare, LLC or to Michael H***, DMD (owner) depending on how the insurance carrier has decided to set that up in their system (the TAX ID number is the same either way).it appears in the client's case she had asked that a modification in the standard workflow be followed, in that she wanted the reimbursement from the Aflac insurance check to be sent to her instead of to Certus DentalCareAs outlined above, it is unusual for Certus to file a claim to an insurance company on a patient's behalf and then have the reimbursement check go back to the patient, not to Certus for our services renderedAlthough it is possible to be done this way for noncontracted insurances such as Aflac, patients are typically requesting the submission of a claim so that the Practice can receive reimbursement for services rendered, not so the patient can receive the reimbursement checkHowever, if that is what client desires, we can reimburse her for the amount of money we received from AflacI have already authorized our office manager to request a check for $575,from our bookkeeper to be sent to the clientWhen the client initially contacted us with the request to reimburse her the money that was paid by Afiac, the office manager declined since it would be against office policy to refund money to a patient for reimbursement made out to the Practice bv an insurance companyThe office manager did offer an alternative solution to the client to refund the copayment ($494.02) she personally paid (which is allowable under office policy), which was close to the amount that had been paid by Aflac to Certus, but the client refusedAlso to note, we are still waiting for reimbursement from claims submitted on behalf of the client for the dental work that has been completed at this time.Based upon the information documented and provided by our office manager, there are several other factors that caused this case to be more complex than what we see on a day to day basisOur office is contracted with the client's dental insurance carrier, United ConcordiaWe have received previous correspondence from United Concordia regarding the client's account that states that United Concordia is primaryTherefore, we needed to submit claims to United Concordia as weli for her accountTypically a secondary insurance (Aflac, in this instance) will not pay unless it has been billed to the primary firstThe client's letter implies that requests to speak with people in authority were deniedThe Certus office staff that was in authority to speak with her regarding this case did speak to her extensivelyThe office manager IS the highest level of authority and has the knowledge to speak to patients about billing and claims Questions, A? a dentist, I do not have the level of expertise that my business office staff have regarding eligibility, claims submission and reimbursement and that is why I delegate that responsibility to themOur Insurance Verification Specialist, Billing & Collection Specialist and Office Manager have well over years of experience collectively in the industry, therefore I leave it to them to speak with authority and expertise to patients regarding those issuesThe client did have an opportunity to speak with ail of them at various points on the phone and in person in working through this issueThe client also refers to the wife in her letterShe does not handle insurance verification, claims submission nor claims reimbursements (her primary role with office finances is to oversee the office bookkeeper for oversight of the practice and payment of bills)Additionally, I have been told that the client did speak with her direct clinical providers (the dental assistant and DrHanlon) who also referred the client to speak further with the front office staff listed above who could best address her questions.The client's letter also notes a concern regarding billing under an incorrect providerWe do not know what she is referencing with that statement in that as explained above our office has one Tax ID numberMost times the claim will show under the LLC (Certus), but may also show under a dentist name either Michael H*** (owner) or Justin Hanlon (associate/employee) if he was the dentist that performed the procedure.The clienfs letter states that she came in for an appointment that the office did not have record of her visit being scheduledOur office utilizes Lighthouse software that communicates with patients via texts or emails for upcoming appointments as well as remindersThe software report does not show that a message was sent to the client notifying her or confirming that the patient had an appointment on that day.Our office does our best to check eligibility, submit claims and post claims payment accuratelyWe have been doing this for years while navigating the sometimes complex insurance companies' processesWe are typically able to perform this well, as a service to our valued patientsHowever, on occasion we come across some more difficult ones to work through or make human errors and therefore we appreciate the patients who are able to work through those instances so that additional knowledge and experience can be gained as they work with us to reach a positive and accurate outcome.Living and working in the community where my practice is owned and my family is raised, it is important to me that my practice is a representation of my desire to provide excellent dental care and service to my patientsI am sure my office staff will learn from this experience, and I hope that the client will be able to find a suitable dental provider fn the future for her needs.Sincerely,Michael *H*** D.M.DOwner, Certus DentalCare, LlC
11-20-17RE: Case ID #12499693To whom it may concern,We received the correspondence regarding the complaint from our patient, who will be referred to as the "client" in this letterIn order to address the concerns In this complaint, I would like to demonstrate and outline for you that Certus
DentalCare, LLC does have policies and workflows in' place to educate patients regarding financial expectations and to submit and process claims in a standardized manner with accordance to insurance guidelinesEach patient signs a financial policy that addresses that our office will submit claims as a courtesy to our patients which this client did sign (attached)Next, our insurance verification specialist checks the chart prior to each visit and contacts our contracted Insurance companies to verify eligibility prior to each appointment, which was verified with United Concordia prior to the client's visitSubsequently, if a patient requires dental work, a good faith estimate is provided to the patient that outlines what the patient may owe in terms of a copay for their services based upon the most recent fees the insurance agency has provided us, what we can see in the insurance company's data base at that time regarding what claims have been submitted/processed in relation to their copays, deductibles and maximum reached, as well as their eligibilityAli this information changes frequently as claims are posted to their website, fees are updated and members eligibility changesTherefore, we tell patients (and it is written on the estimate sheet) that only after the insurance processes the claim will we know for sure how much they oweTypically our office estimates are fairly accurate for this system to be of benefit to our patientsThe estimate presented to the patient shows what insurances we are planning to submit to as per the information we have on file for the patient (which was presented to the client)Also the workflow is to submit the claim to the insurance company on the patients behalf and the insurance company then submits a check to the practice (either Certus DentalCare, LLC or to Michael H***, DMD (owner) depending on how the insurance carrier has decided to set that up in their system (the TAX ID number is the same either way).it appears in the client's case she had asked that a modification in the standard workflow be followed, in that she wanted the reimbursement from the Aflac insurance check to be sent to her instead of to Certus DentalCareAs outlined above, it is unusual for Certus to file a claim to an insurance company on a patient's behalf and then have the reimbursement check go back to the patient, not to Certus for our services renderedAlthough it is possible to be done this way for noncontracted insurances such as Aflac, patients are typically requesting the submission of a claim so that the Practice can receive reimbursement for services rendered, not so the patient can receive the reimbursement checkHowever, if that is what client desires, we can reimburse her for the amount of money we received from AflacI have already authorized our office manager to request a check for $575,from our bookkeeper to be sent to the clientWhen the client initially contacted us with the request to reimburse her the money that was paid by Afiac, the office manager declined since it would be against office policy to refund money to a patient for reimbursement made out to the Practice bv an insurance companyThe office manager did offer an alternative solution to the client to refund the copayment ($494.02) she personally paid (which is allowable under office policy), which was close to the amount that had been paid by Aflac to Certus, but the client refusedAlso to note, we are still waiting for reimbursement from claims submitted on behalf of the client for the dental work that has been completed at this time.Based upon the information documented and provided by our office manager, there are several other factors that caused this case to be more complex than what we see on a day to day basisOur office is contracted with the client's dental insurance carrier, United ConcordiaWe have received previous correspondence from United Concordia regarding the client's account that states that United Concordia is primaryTherefore, we needed to submit claims to United Concordia as weli for her accountTypically a secondary insurance (Aflac, in this instance) will not pay unless it has been billed to the primary firstThe client's letter implies that requests to speak with people in authority were deniedThe Certus office staff that was in authority to speak with her regarding this case did speak to her extensivelyThe office manager IS the highest level of authority and has the knowledge to speak to patients about billing and claims Questions, A? a dentist, I do not have the level of expertise that my business office staff have regarding eligibility, claims submission and reimbursement and that is why I delegate that responsibility to themOur Insurance Verification Specialist, Billing & Collection Specialist and Office Manager have well over years of experience collectively in the industry, therefore I leave it to them to speak with authority and expertise to patients regarding those issuesThe client did have an opportunity to speak with ail of them at various points on the phone and in person in working through this issueThe client also refers to the wife in her letterShe does not handle insurance verification, claims submission nor claims reimbursements (her primary role with office finances is to oversee the office bookkeeper for oversight of the practice and payment of bills)Additionally, I have been told that the client did speak with her direct clinical providers (the dental assistant and DrHanlon) who also referred the client to speak further with the front office staff listed above who could best address her questions.The client's letter also notes a concern regarding billing under an incorrect providerWe do not know what she is referencing with that statement in that as explained above our office has one Tax ID numberMost times the claim will show under the LLC (Certus), but may also show under a dentist name either Michael H*** (owner) or Justin Hanlon (associate/employee) if he was the dentist that performed the procedure.The clienfs letter states that she came in for an appointment that the office did not have record of her visit being scheduledOur office utilizes Lighthouse software that communicates with patients via texts or emails for upcoming appointments as well as remindersThe software report does not show that a message was sent to the client notifying her or confirming that the patient had an appointment on that day.Our office does our best to check eligibility, submit claims and post claims payment accuratelyWe have been doing this for years while navigating the sometimes complex insurance companies' processesWe are typically able to perform this well, as a service to our valued patientsHowever, on occasion we come across some more difficult ones to work through or make human errors and therefore we appreciate the patients who are able to work through those instances so that additional knowledge and experience can be gained as they work with us to reach a positive and accurate outcome.Living and working in the community where my practice is owned and my family is raised, it is important to me that my practice is a representation of my desire to provide excellent dental care and service to my patientsI am sure my office staff will learn from this experience, and I hope that the client will be able to find a suitable dental provider fn the future for her needs.Sincerely,Michael *H*** D.M.DOwner, Certus DentalCare, LlC