Kaiser Permanente of Washington

Complaint: [redacted] I am rejecting this response because it was not the complain for the service provider It was the complain for the staff at Kaiser, who worked at the call center They were not doing their job when I asked for the health plan coverage and policy It was her job, but she thought the out of network service provider would had looked it up for me It was ethical All she needed to do, was answered my question and looked up the health plan information for me She was already treated me like a fool She set the phone on hold for over minutes and purposely wasted my time Normally, I could have easily hanged up and talked to a difference representative I talked to many staff at the call center, but Adrian and Steve had so much attitude, I couldn't even stand for a chance and decided to file a complaint It was really simply for the quality of service Sincerely, [redacted] ***

I am writing in response to your January 13, (Received by our office January 25, 2017)inquiry on behalf of Mr [redacted] received by Group Health Cooperative.We understand Mr [redacted] expresses frustration regarding his cancellation of COBRA coveragewith Group Health and subsequent refund of premiums.We apologize for the negative experience Mr [redacted] may have encountered with his choice toend his coverage with Group HealthA review of our records indicates the following:• Customer Service received a request for coverage termination on November 29, to be effective December 1, 2016.• That termination completed on December 5, effective to the December 1, requested date.• Review of the premium payments determined that the premium for December had indeed been paid in advance on November 26, and would thereby be due for refund.• A refund request was processed on December 27, and requested to the Master Card ending --***.• That refund amount was processed for $under batch reference # [redacted] **.• For convenience and his privacy, a copy of the receipt for that transaction along with this letter will mail directly to Mr [redacted] again for his records.Thank you again for taking the time to bring this to our attentionIf you have any questionsregarding this matter, you may reach me at [redacted]

Dear Ms [redacted] :I am writing in response to your November 28, follon behalf of Mr [redacted] receivedby Group Health Cooperative We understand Mr [redacted] expresses continued frustration that the invoice statements and paymentsaccount analysis from have not been receivedMr [redacted] is enrolled on an individual & familyCore Silver HSA plan, purchased through the Washington Health Benefit Exchange (WAHBE)Weapologize for any inconvenience this may have caused We have again confirmed the documents requested by Mr [redacted] were mailed to the following address: [redacted] Sammamish, WA This address agrees with both the account informationon file with Group Health and the address listed for the complaint We are unable to identify what may have prevented him from receiving those documents as requested.To ensure that Mr [redacted] receive both the invoice statements and the payments account analysisas requested, he may reach me directly at [redacted] Monday thru Friday 9am-4pmI will gladlymake arrangements for the documents to be received in another manner if convenientWe can certainlyfax them to him direct if he chooses We also understand Mr [redacted] has continued concerns regarding premium invoices not received fromGroup Health for months prior to October 2015; we can confirm that Group Health began acceptingpremium payments from WAHBE enrolled members through the agreed payment vendor, Softheon,effective October of We did issue an invoice to Mr [redacted] for his November coverage datedOctober 13, Any premium invoices issued prior to October 1, would have come directly fromWAHBE Thank you again for taking the time to bring this to our attentionIf you have any questions regarding thismatter, please contact me Sincerely, Rebecca H**Health Plan Administration

Please see attachment for Revdex.com response I am writing in response to your July 21, inquiry on behalf of Mr [redacted] , received by Group Health CooperativeWe understand Mr [redacted] expresses frustration in regards to his care received and the timelinessUpon research I was advised by Group Health Medical Center, Facility Manager: Cindy [redacted] that she has spoken with Mr [redacted] in great extent and assisted with all details of his concerns listed in his complaint, We sincerely apologize for the any negative experience Mr [redacted] may have encounteredThank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at [redacted]

I am writing in response to your August 3, inquiry on behalf of Ms [redacted] , requesting additional details from Group Health Cooperative in regards to her original complaintPlease provide a response addressing the consumers concerns regarding the time- frame of the billing process and how that may impact the businesses appeal process: Group Health billed Regance, business days after Ms [redacted] received services at our Olympia Medical Center-Urgent CareRegance accepted the claim on May 30, Regance provided an explination of benefits (EOB) to Ms [redacted] ; at that point it was her responsibility to communicate with Regance to dispute or appealRegance did not communicate with Group Health after the initial billed dateGroup Health billed the member billing cycles (indicated in the previous response)Ms [redacted] will need to communicate with Regence for further assistance in regards to the billing time frame and her appealsThank you again for taking the time to bring this to our attention

Dear [redacted] :I am writing in response to your April 24, inquiry on behalf of Ms [redacted] received byKaiser Foundation Health Plan of Washington.We understand Ms [redacted] expressed frustration with a recent encounter for prescription with careteam personnelShe requested a formal complaint regarding the behavior she described as rudeand disrespectful and has requested contact back from supervisory level management regarding theincident.We can confirm that Kaiser Permanente has received and is working this complaint for Ms***.We have been in communication with the clinic management in regards to this incidentAt this timewe can assure Ms [redacted] that communication is continuingWhile we are not at liberty to suggestany outcomes related to the employee or our internal investigation, we will update Ms [redacted] withany information we can related to the reviewWe have confirmed management did make initialcontact with Ms [redacted] on 5/3/and have noted follow up will occur.Thank you again for taking the time to bring this to our attentionIf you have any questions regardingthis matter, you may reach me at 206-630-1573.Sincerely,Rebecca H**Health Plan Administration

I am writing in response to your February 24, inquiry on behalf of [redacted] received by Group Health Cooperative.We understand Mr [redacted] expresses frustration related to the copays recently applied tomedication fill for his entire family for December 2016.We apologize for the negative experience Mr [redacted] may have encounteredIn consultationwith our pharmacy group, a review of this encounter, confirms the following:• The processing of copays charged to Mr [redacted] is a condition of how theprescriptions were written and filled, not the number of prescriptions.• It would be typical that a separate prescription should be written for each family memberreceiving medication, even though it was a situation that intended to treat the wholefamily.• Medication copays are determined by the dose and prescription details, per day fill.• In this instance, each family member receiving the medication as prescribed should havecarried with it a $copay up to days for each family member.• The prescription should have included the first tablets per family member and 4th pilltaken weeks later, which for family members should have been a total of $copay.• However, because this prescription was written as a quantity to be taken by the entirefamily, and in two doses, the copay was calculated as follows.• The first prescription for tablets, in agreement with the written dose instructions,calculated as a day supply of the medication, which applied $copay up to a dayfill for total copay $toward day supply.• With the additional prescription of tablets the copay assigned was $up to day fill.• Together the medication fills, as prescribed, had a correct copay total of $75.Group Health CooperativeHealth Plan AdministrationEMarginal Way SSeattle, WA 98168800-833-TTY Relay206-901-Faxwww.ghc.org Thank you again for taking the time to bring this to our attentionIf you have any questionsregarding this matter, you may reach me at [redacted] Sincerely,Rebecca H**Health Plan Administration

Please see attachment January 11, 2017Attn: [redacted] *** Revdex.comRe: Consumer: [redacted] ID Number: [redacted] Revdex.com Number: [redacted] Dear Mr***:I am writing in response to your January 2, inquiry on behalf of Ms [redacted] * [redacted] received by Group Health Cooperative We understand Ms [redacted] expresses frustration and concern regarding the recent receipt of her medications orders and the documents included in that package We apologize for any negative experience Ms [redacted] encountered with this process Excellent service is our highest priority, as is the protection of our member’s information On November 6, 2016, Group Health implemented a change to our pharmacy system• With the pharmacy system change, the patient instruction document we are required to send with prescriptions was customized to include basic patient identifiers (name and Rx #)• The individual packing her order inadvertently included the wrong document in her mailing• The Group Health Privacy Office spoke to the Complainant on December 28, 2016, and actively investigated her privacy concernsAt this time, we have no indication that her information was sent to another patient • In the interest of protecting the information of all our members and ensuring that this does not occur again, processes have been changed to remove all patient identifiers on these instruction sheets.In support of the privacy of the other patient named in this complaint, please redact that patient’s name from the complaint document Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at 206-630-Sincerely, Rebecca H** Health Plan Administration

I am writing in response to your April 21, 2017 inquiry on behalf of Ms. [redacted] received by Kaiser Permanente. We understand Ms. [redacted] expressed concern regarding her recent radiology service as part of an urgent care visit. She requests that the plan cover the cost of x-rays from... the urgent care visit as well as the CT scan later utilized to further review her condition as she believes had the x-ray been of better quality the CT scan would not have been necessary. Kaiser Permanente did receive an appeal request to review these services for Ms. [redacted] and asking for the plan to cover all costs of both services. The benefit for radiology services under Ms. ***’s plan are subject to her $2,000.00 deductible and 30% coinsurance once the deductible is satisfied. The appeal upheld the decision that both services were provided and processed correctly to the coverage with assignment toward the deductible. Although her physician did indicate that the x-ray views were light and made any bone fracture difficult to see, he also confirmed that based on her severe pain, further evaluation may be needed and recommended a CT scan of the hip to look for “hidden fracture.” It would be reasonable that the additional CT scan was appropriate to further evaluate the pain and difficulty Ms. [redacted] was experiencing. However, as a courtesy and in the interest of customer satisfaction, we are requesting the x-rays received during her urgent care visit reprocess and the plan make payment for the amount assigned to Ms. ***’s deductible for $139.57. Ms. [redacted] should receive an additional explanation of benefit (EOB) for this service once the claim reprocessing is complete. Thank you again for taking the time to bring this to our attention. If you have any questions regarding this matter, you may reach me at [redacted]

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to meSincerely, [redacted]

I am writing in response to your May 25th inquiry on behalf of Ms [redacted] ***, received byGroup Health Cooperative.We understand Mr [redacted] expressed frustration in regards to being billed in full for servicesreceived in MarchI have confirmed with our Membership Department as well as the HealthBenefit Exchange (HBE) that Ms***’s medical coverage termed March 1st as a result of hernotifying HBE of her increased income on February 3rdShe was advised that her subsidy of$was no longer in effect and her monthly responsibility was going to increase from $114.74to $effective March 1stOn March 3rd Group Health received a payment of $114.74, butnever received the balance of $to satisfy the total premium, because of this, coverage wastermed on April 14, retro back to March 1st.I confirmed in our data base that on March 25, 2016, 3:45pm, Dr [redacted] apologized to Ms[redacted] for the erroneous information (scheduled procedure and associated diagnosis) that wasmistakenly placed in her chartIn addition he advised that our staff checked to be sure that noneof Ms***’s information was placed in the other patient's chartThere was nothing added to theother person's recordThe records were not mixed upThe order intended for the other personwas simply absent from her chartThe schedulers had already caught the error prior to Dr[redacted] speaking with Ms***He acknowledged the error and repeatedly apologizedI amgrateful that we have a policy that gives patients access to their charts, and that we have multiplestops in our system where data is checked.Thank you again for taking the time to bring this to our attentionAgain we sincerely apologizefor the negative experience Ms [redacted] encountered.Regards,Terri N***Health Plan Administration

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to meIt's too bad that it took this complaint to get a response Perhaps the fact that they referred to me by a completely incorrect name in the letter may indicate that carelessness on their part may be part of the problem.Sincerely, [redacted]

January 30, 2018Re: Consumer: [redacted] *** for daughter’s care/servicesID Number: [redacted] Revdex.com Number: [redacted] I am writing in response to your January 22, inquiry on behalf of [redacted] received byKaiser Foundation Health Plan of Washington.We understand [redacted] submitted a follow up to her complaint redirecting attention to theinteractions she experienced with Member Services for her concerns and benefit informationSheshared that she expected all the representative needed to do was answer the questions and providethe health benefit informationHer interaction with the representative and her manager did notresolve the issue and [redacted] shares she felt that she was treated like a fool.Our review of the specified encounters with Member Services, did identify opportunity for improvedcommunication regarding [redacted] ***’s concernsWe acknowledge that the telephone interaction withthe representative was a lengthy and confusing experience for [redacted] ***.We apologize that because Fraud Waste and Abuse had already contacted [redacted] ***, Managementdid not make any additional call to confirm resolution of the issue.An additional level of Management completed a review of the interactions and coaching wascompleted to ensure a better customer experience in the futureWe appreciate [redacted] ***’scommitment to sharing her feedback with us, and we apologize for not addressing this concern moredirectly in our prior response.Thank you for contacting Kaiser Permanente on behalf of [redacted] ***Should you have anyfurther questions, regarding this matter, please feel free to contact me at [redacted] Sincerely,Rebecca H.Health Plan Administration

Complaint: [redacted] I am rejecting this response because:The Group Health / Kaiser Permanente is trying to bend the facts to fit their policies (like stating incorrect treatment course that fits prescriptions)It looks this policy is not aligned with the medical procedure, with Group Health applying existing policies at the expense of patients.My facts:We were given only one prescription for a single person (the admitted patient) for tablets onlyNeither Bartel Drugs nor Group Health Pharmacy could find the secondIt took me or calls to Group Health trying to locate the missing part, I ended up with consulting nurse who I believe engaged a doctor to issue a new prescription that was sent to Group Health PharmacyThe treatment course is weeks only, not or or days - two dozes weeks apartThe treatment course for a single person does includes family members as well, but it's not a treatment for peopleFamily members are given this medicine only as a part of the admitted patient treatment, not as separate patientsIf insurance policy doesn't recognize family medical procedures then either change the policy or instruct your Urgent Care department to invent another treatment for a single personNo implications were explained during the Group Health Urgent Care visit, and from medical point of view only one person is treated (thus our prescription for only one person, not multiple prescriptions for each family member)During the visit we were told the prescription is for the complete course, not doze with an option to figure out where the other is Sincerely, [redacted]

I am writing in response to your April 4, inquiry on behalf of Ms*** received byGroup Health CooperativeThank you for taking the time to forward her concerns to us.Ms*** voices a concern of a $bill, resulting from three urgent care visits at our*** *** Urgent Care
We understand that she feels there may have been a misdiagnosis onher first two visits, requiring a third visit in which a correct diagnosis was made.We apologize for what can feel like a frustrating experience with multiple visits to Urgent Care.Dr*** ***, Emergency Services Physician, performed a detailed review and it has beendetermined that the treatment provided to Ms*** and the medical decisions made,were sound and appropriateA claims review was also completed based on Ms***request that Group Health provide compensation for her first two urgent care visitsSince themedical treatment provided in all three office visits were determined to be appropriate, we arenot waiving any cost associated with those visits.It is not easy to hear that any member is not satisfied with some aspect of our service; wesincerely apologize for any frustration Ms*** may have experienced.Thank you again for taking the time to bring this to our attentionIf you have any questionsregarding this matter, you may reach me at ***Sincerely,Terri ***Health Plan Administration

Dear Ms***:
I am writing in response to your July 14, inquiry on behalf of Mr*** received by Group Health Cooperative.
We understand Mr*** expressed concern with the service he and his spouse (***) received at our Group Health Bellevue - Emergency
Room on March 22,
We apologize to them both for the negative experienceI have shared the concerns with the manager of that department and as requested, both $copayments have been reversedThe $copayment for Mr*** was in collections (now pulled out and reversed without penalty to credit)The $copayment for Mrs*** has been processed for a refundIn days a refund check is being sent to the mailing address listed in our system
Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at 206-901-
Sincerely,
Terri N***
Health Plan Administration

I am writing in response to your follow up request January 18, inquiry on behalf of Mr*** ***, received by Group Health Cooperative
We understand Mr*** continues to expresses frustration in regards to the services for the flu shot received on October 6, not being coveredWe apologize for any inconvenience this may have caused
While we do understand Mr*** frustration, we again would like to remind that the presentation of a medical insurance card does not guarantee coverage for servicesGroup Health can and does bill services for Premera members
A review of the billing records for the services confirms the following:• Vaccine services were received on October 6, 2016.• We do not verify non-Group Health insurance benefits for this service.• It would be up to the patient to know if their insurance covers them to come to Group Health for a flu shot.• A signed consent form authorizing the vaccine service is on file indicating “If I owe a cost share, I will be billed for my portion.”• Group Health billed Premera insurance for the services on October 20, 2016.• Explanation of Benefits was received October 25, denied by insurance as not provided by network or primary care providers.• As a result, the vaccine services were billed as patient responsible balance
Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at 206-630-

January 19, 2018Re: Consumer: *** *** *** *** ***ID Number: *** Revdex.com Number: ***I am writing in response to your January 10, inquiry on behalf of *** *** *** received byKaiser Foundation Health Plan of Washington.We understand *** *** submitted a complaint
regarding the quality of service her daughter wasreceived from a contracted providerShe made several calls to Member Services to makecomplaints about this provider, including accusations of fraud*** *** also shared concerns abouta variety of hold times when checking benefits and information about her coverage with MemberServicesShe also shares that contact to a manager did not resolve her concerns regarding theprovider.Our review confirmed *** *** did share concerns regarding the service of an outside provider forher daughter’s needsKaiser Permanente does accept feedback and complaint regarding servicesreceived by contracted providersBecause these providers are not directly Kaiser Permanenteproviders, our ability to resolve issues can be limitedHowever, when concerns of fraud or care areraised, we have a review process to access the level of response necessary given the complaint.We understand from the complaints that *** *** seems to have had expectations regarding thescheduling and staffing as well as their general policies which included billing for the providerOurprocess encourages members to communicate their concerns directly to the providerTheallegations of fraudulent billing practices were shared with the Kaiser Permanente Fraud Waste andAbuse Department for review.While we cannot share the detail of this investigation, we can confirm that no billing issues wereidentified for this member’s servicesAn additional audit of a larger sample of claims were reviewed,but did not identify any billing issue and continued audit was determined unnecessaryWe confirmthat the investigator with the Fraud Waste and Abuse Department contacted *** *** to share theseresults with her and encouraged her to communicate her complaints directly to the provider.We apologize for the negative experience *** *** may have encountered with this provider.Management confirms that because FW&A personnel had already contacted her, additional callswere not made to *** ***, as no new information or response was availableWe acknowledge thatdepending on the time of year or circumstances, hold times to reach member services can be longerthan desiredOur review did not identify any interaction where representatives or managementrefused to assist *** *** with any requestIf she has specific representatives or dates of her call wecan review further.Should *** *** wish assistance in locating an alternate provider for her daughter’s care, ourMember Services staff can assist her or our on-line provider directory may be utilizedThank you forcontacting Kaiser Permanente on behalf of *** *** ***Should you have any further questions,regarding this matter, please feel free to contact me at ***Sincerely,Rebecca H.Health Plan AdministrationKaiser Foundation Health Planof Washington Options, Inc.Member Grievance DepartmentP.OBox 34593Seattle, WA 98124206-630-1573800-833-TTY WA Relay206-630-Fax

I am writing in response to your February 23, inquiry on behalf of Ms*** received by Group Health Cooperative We understand Ms*** expresses frustration with being sent to collectionsI worked with our Patient Financial Services (PFS) Supervisor, who advised Ms*** had
previous charges that aged to a past due statusServices provided last summer and fall were billed but returned by the United States Postal Services as “not deliverable address”A phone message was left on 9/24/at the number we have on file, “***”.Member contacted PFS on 11/11/to negotiate a payment arrangement but no address update was providedHer billing cycle was reset and her updated bill and payment plan confirmation letter were sent to the address on fileThe letter reached the patient because she has a copy per her complaint, but the billing statement was returned “undeliverable” by USPS againAnother attempt to contact the patient was made on 12/11/at the phone number on file with no responseOn 12/16/the charges were assigned to Evergreen Professional Services as bad debt /return mailWithout a valid address, Group Health does not continue to bill We apologize for the negative experience Ms*** have encountered Thank you again for taking the time to bring this to our attention

Dear Ms***I am writing in response to your June 23, 2016, inquiry on behalf of Ms*** *** received by Group Health Cooperative.We understand Ms*** expresses frustration in regards to being billed $for the Durable Medical Equipment (DME) (wrist position corrector) provided to her
during her May 4, appointment.We apologize for the negative experience Ms*** may have encounteredIt was determined that during Ms***’s office visit she was provided a diagnosis of carpal tunnelOur providers try to provide a medical remedy in the moment whenever possibleProviders are not aware of member plan types or any cost associated with the devicesThis is not done at all as a selling tactic; they simply are not the experts in medical benefit coverage and it has been communicate that they advise members to check benefit coverageIt is also best that you contact our Customer Service department (1-888-901-4636) for any medical benefit questions prior to accepting DME itemsAs a courtesy we have reversed the $for you.Thank you for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at 206-901-7632Sincerely,Terri N***Health Plan Administration