Institute for Gynecology and Minimally Invasive Surgery

January 5, 2017Dear [redacted]:Please be advised that this Firm represents Women's Institute for Gynecology and Minimally Invasive Surgery, LLC, We are responding in that capacity to your letter dated December 22, 2016, received by my client by mail on December 27, 2016, within the requested ten...

(10) day time frame.Enclosed you will find the standard Business Questionnaire completed by my client and all documents referred to in this position statement in response to [redacted]' Complaint, apparently on behalf of his fiancée, [redacted], It is unfortunate that [redacted] has become involved in this matter, and that the patient, [redacted], did not cooperate with my client's significant efforts to obtain insurance coverage under the circumstances outlined below. You will see from the enclosed communications from this office to [redacted] and [redacted] and to [redacted] Insurance Company, that my client remains willing to assist them in that effort despite having filed this Complaint with the Revdex.com.[redacted] presented to my client's office with the enclosed insurance identification card with [redacted] in the name of [redacted], In the normal course, my client contacted [redacted] on behalf of [redacted] and was advised that the anticipated procedure was a covered service and required no pre-certification or pre-authorization, My client's office again contacted the insurer a week later and re-verified that no pre-certification or pre-authorization was required and that the anticipated procedure was a covered service.My client had [redacted] sign the Surgical Financial Statement enclosed confirming that they would verify insurance coverage prior to the procedure and collect any patient responsibility amounts prior to the procedure, but that the insurance policy is a contract between patient and the insurance carrier and the patient is ultimately liable for any patient responsibility stated on the insurance carrier's Explanation of Benefits, My client collected the estimated patient responsibility amount of $203.60, The procedure was then successfully performed with the full expectation on the part of my client, and apparently [redacted], that it was a covered procedure and any remaining amounts clue would be paid on her behalf by her insurance company.After submitting the invoice for payment to the insurance carrier, my client received the enclosed letter dated March 21, 2016 indicating that the claim had processed correctly and was denied, My client engaged in a series of phone calls as indicated on the enclosed log confirming that the insurer had originally confirmed benefits without pre-certification or pre-authorization, but subsequently denied payment on the basis of failure to pre-certify and receive pre-authorization, Upon further investigation, as indicated in the enclosed log, the insurance company acknowledged that they had misquoted the plan benefits and that the patient would need to file an appeal to have the procedure covered and my client paid.My client drafted an appropriate letter dated April 14, 2016 to the insurance company on behalf of [redacted] and communicated with her and sent the enclosed draft letter to her for signature and return to my client for purposes of submitting it on her behalf to the insurance company. [redacted] never responded and, to the best of my client's knowledge, never signed or independently submitted an appeal letter to her insurance carrier,Accordingly, pursuant to the Surgical Financial Statement, my client began submitting statements for the amount remaining due to the patient, as indicated on the enclosed Statement of Account. [redacted] has never responded with payment, and her file was turned over in the normal course for collection, The current account balance is also enclosed. Because. [redacted] did not cooperate with filing an appeal, and the entire amount remained due under the insurance carrier's Explanation of Benefits, the collection will continue and she will be obligated not only for the principal amount due, but interest and collection fees. [redacted] never responded in any way to the collection efforts, as indicated on the attached log from [redacted].Unfortunately, the normal time for processing an appeal administratively may have expired, but my client remains willing to assist [redacted] in submitting the appeal and pursuing the insurance carrier directly on the basis of its negligent management of the verification process. If my client ultimately succeeds in collecting from [redacted] for the allowable around it will reduce the financial obligation of [redacted], but she would remain responsible for collection costs and fees. If [redacted] pays the full $3,791.40 amount to my client, my client will waive the collection costs and fees.As you can see, nothing improper or deceptive was done at any time by anyone by or on behalf of my client in regard to this matter, and the fault remains with the insurance carrier for misquoting benefits at the outset and, candidly, with [redacted] in failing to cooperate withsubmitting the appeal in a timely manner.If you require any additional information in aid of your consideration of this Complaint, please do not hesitate to contact me directly. It is our position that the Complaint is unfounded, and should not be made a matter of permanent record in your files or published in any way in a manner adverse to my service.Thank you for your anticipated cooperation in this regard.Sincerely,