Kaiser Permanente of Washington

I am writing in response to your January 13, 2017 (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 Health. A review of our records indicates the following:• Customer Service received a request for coverage termination on November 29, 2016 to   be effective December 1, 2016.• That termination completed on December 5, 2016 effective to the December 1, 2016   requested date.• Review of the premium payments determined that the premium for December had indeed   been paid in advance on November 26, 2016 and would thereby be due for refund.• A refund request was processed on December 27, 2016 and requested to the Master Card   ending --[redacted].• That refund amount was processed for $576.70 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 attention. If you have any questionsregarding this matter, you may reach me at [redacted]

Complaint: [redacted]I am rejecting this response because:
The response is misleading and ignores facts:1. Nobody says presentation of a medical insurance card guarantees coverage. That's why we always check the coverage of insurance before service is done. The representative of Group Health did check my new insurance card and told me explicitly it's covered.2. Your response says "We do not verify non-Group Health insurance ..." However, your representative did check it and told me it's fine to use the new insurance card.3. Even if I signed a form indicating "If I owe a cost share, I will be billed for my portion.”,  that was after your representative told me that the new insurance card was fine.If I were not misled by your representative, I could have lots of other options to take a flu shot with 100% coverage!I urge your company considering the above facts and address the issues positively instead of just ignoring clear facts. Paying $50 is not a big deal, but the way of treating customers by your company is totally unacceptable. Your company misled me but have never recognized the mistake. By the way, I have never seen a sincere response or apology from your company. Sincerely,[redacted]

I am writing in response to your June 15, 2017 inquiry on behalf of Ms. [redacted] [redacted] receivedby Kaiser Permanente.We understand Ms. [redacted] submitted a complaint regarding her coverage from fall of 2016 for whichshe believes she but is now being billed. Ms. [redacted] feels she is being harassed...

by having receivedthese bills.Our records confirm that Ms. [redacted] requested enrollment for an Individual & Family plan inSeptember 2016. However, because that enrollment occurred outside of the open enrollmentperiod, on September 8, 2016 we sent notification that additional documentation (proof of qualifyingevent) was needed. That notice indicated documents must be received within 30 calendar days toavoid cancellation of enrollment. We did not receive any documentation or reply from Ms. [redacted] Asa result; we sent an ineligible coverage letter on October 12, 2016.Ms. [redacted] made a payment for coverage on September 13, 2016 in the amount of $256.95;however, because of the ineligible enrollment this payment was refunded to her Visa card onOctober 14, 2016. We do not find any additional contact, effort to make premium payments, orinquiry regarding the ineligible enrollment.We also confirmed that Ms. [redacted] was active on an employer COBRA plan from February 1, 2016 toOctober 1, 2016. However, notification for termination of this plan was received and processed onNovember 10, 2016 to be retroactive to October 1, 2016. Ms. [redacted] had medical treatment onOctober 4, 2016 which included vaccinations and laboratory services. Originally, these servicesprocessed on October 7, 2016 with payment by the COBRA coverage which was still active at thetime of service. However, our claims department reprocessed those claims in March 2017 to deny,given the retroactive termination. Because COBRA coverage termed, and the Individual & Familyplan was not active, the services from October 4, 2017 were denied subsequent to termination andassigned as full member responsibility.The Kaiser Permanente Patient Financial Services (PFS) Department started billing Ms. [redacted] onMarch 8, 2017 for these reprocessed claims. Once a service is billed with three billing cycles of nonpayment,any unpaid balance is placed with our collections agency. The $72.00 referenced in Ms.[redacted]’s complaint is for laboratory services from October 4, 2016 that first billed to Ms. [redacted] withthe May 9, 2017 PFS billing statement. Our Patient Financial Services Department may be reachedat the information listed on those billings for any questions or assistance.Thank you again for taking the time to bring this to our attention. If you have any questions regardingthis matter, you may reach me at [redacted].Sincerely,Rebecca H**Health Plan Administration

I am writing in response to your February 24, 2017 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 encountered. In 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 30 day fill.• In this instance, each family member receiving the medication as prescribed should havecarried with it a $25 copay up to 30 days for each family member.• The prescription should have included the first 3 tablets per family member and 4th pilltaken 2 weeks later, which for 4 family members should have been a total of $100 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 12 tablets, in agreement with the written dose instructions,calculated as a 56 day supply of the medication, which applied $25 copay up to a 30 dayfill for total copay $50 toward 60 day supply.• With the additional prescription of 4 tablets the copay assigned was $25 up to 30 day fill.• Together the medication fills, as prescribed, had a correct copay total of $75.Group Health CooperativeHealth Plan Administration12401 E. Marginal Way SSeattle, WA 98168800-833-6388 TTY Relay206-901-4590 Faxwww.ghc.org Thank you again for taking the time to bring this to our attention. If you have any questionsregarding this matter, you may reach me at 206[redacted]Sincerely,Rebecca H**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 me.
the business needs to better inform its clients of any possible additional charges any services may incur and allow them to make decisions base on prices.
without informing clients "sale" has happened and send them bills is a gross technique for enhancing sales. they should stop it.
Sincerely, [redacted]

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 30 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]

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:1. We were given only one prescription for a single person (the admitted patient) for 12 tablets only. Neither Bartel Drugs nor Group Health Pharmacy could find the second. It took me 3 or 4 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 Pharmacy.2. The treatment course is 2 weeks only, not 56 or 30 or 86 days - two dozes 2 weeks apart. The treatment course for a single person does includes family members as well, but it's not a treatment for 4 people. Family members are given this medicine only as a part of the admitted patient treatment, not as separate patients. If 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 person. No 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 1.5 doze with an option to figure out where the other 0.5 is.
Sincerely,
[redacted]

I am writing
in response to your January 19, 2017 inquiry on behalf of Ms. [redacted], first received
by Group Health Cooperative offices on January 31, 2017.  We
understand Ms. [redacted] expresses frustration with recent changes in coverage for
herself and dependent via an employer sponsored...

plan.  We apologize for any inconvenience this may
have caused.  A Review of the
enrollment and interactions with Customer Service confirms the following;Ms. [redacted] first contacted Customer Service regarding the indicated request
for termination of coverage on January 19, 2017.  With that contact, she also provided
coverage change documents by fax to request the termination for herself
and dependent daughter. Because her plan is an employer
sponsored plan,  instruction for
coverage changes must be received from the employer and Ms. [redacted] was
advised this with her contact by Customer Service on January 20, 2017 as
response to her fax. Further
investigation with the employer plan account team confirms these additional
details;Group Health did receive two employer submissions for this family
that was looking to change coverage effective January 1, 2017.Both requests were received on the same day December 21, 2016. At this time, contract renewal with this employer was still
pending finalization.On December 23, 2016 the termination of family coverage under the
old employer plan processed effective to January 1, 2017. Simultaneous to the term of the old coverage, the family was
enrolled into the PPO employer plan.Because these requests were both processed on the same day by
separate staff, it appears the family all added to the new coverage in
error. When documentation was received by fax to Customer Service, we
confirmed the group’s employer portal submission and processed the
correction; terming the dependents effective to January 1, 2017.This correction to the employer coverage was completed on January
20, 2017.With the corrections processed, the amount being charged for
coverage was corrected to the employer group for the subscriber only rate
for both January and February. It should be noted, we can only impact the amount we charge the
group, any changes to the amount charged to the individual employee would
be managed by the employer not by Group Health.  Because all coverage changes were effective back to January 1,
2017, there is no dual coverage in effect for Ms. [redacted] or her daughter. One additional review step of
Ms. [redacted]’s Medicare enrollment, also confirms the following:Group Health received an on-line election form to enroll in the
Medicare plan on December 31, 2016. 
The enrollment application was processed and completed on January
3, 2017 and effective to January 1, 2017. 
 For this reason, there is no change in the premiums due for this
coverage.  Please note that no premium payments have been received to date
for this coverage.  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
630-1573. Sincerely,Rebecca H** 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 me. It'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 13, 2017Attn: [redacted]/ Resolutions Consultant Revdex.comRe: Consumer: [redacted] ID Number: [redacted]            Revdex.com Number: [redacted] Dear Mr. [redacted];I am writing in response to your January 6, 2017 inquiry on behalf of Mr. [redacted]...

[redacted] received by Group Health Cooperative.  We understand Mr. [redacted] expresses frustration in regards to the services for the flu shot received on October 6, 2016 not being covered.  We apologize for any inconvenience this may have caused. We apologize for the negative experience Mr. [redacted] may have encountered.  Mr. [redacted] states that he and his spouse presented insurance cards at the time of service.  With the presentation of these cards, a flu vaccination was provided at Group Health Bellevue Medical Center. A review of the coverage information for Mr. [redacted] confirms the following;• Mr. [redacted] previously had Group Health coverage through an employer sponsored options plan which termed January 1, 2016. • Additional research finds no existing Group Health coverage for the calendar year 2016. • On November 9, 2016 Mr. [redacted] contacted Customer Service regarding the billing for the flu shot.• While he stated he had coverage at the time of the service, the Customer Service representative confirmed that coverage terminated under the employer plan with Group Health on January 1, 2016. • If Mr. [redacted] has any other insurance carrier coverage, he may include that information to us for billing.• Presentation of a medical insurance card does not guarantee coverage for services. • With no Group Health insurance coverage in effect at the time the flu shot was given, our billing department correctly assigned the balance for the service as a self-pay balance, and billing statements mailed beginning October 25, 2016. Should Mr. [redacted] wish to make payment toward this billing, he may do so with our billing services department at 1-800-442-4014.   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 206-630-1573. Sincerely, Rebecca H** Health Plan Administration

Complaint: [redacted]
I am rejecting this response because:- the treatment course described by Group Health is wrong, or at least differ from what we were told by the doctor and pharmacists. It should be 2+2 per family member, not 3+1 that fits prescription. We were given one prescription only (and were told it's for 16 tablets), no further instruction to get the rest; I had to make 5 calls to find the missing medicine.- In the urgent care department we were told that this prescription is to fix the patient problem, not other members - we were not even positively tested.- Urgent care didn't give any explanation that each family member should be treated separately (vise versa, it was for the patient only), otherwise we'd probably opt for tests before accepting the treatment. No options were given for the patient if family members reject the treatment (they can be on a separate insurance or other reason).
Sincerely,[redacted]

Complaint: [redacted]I am rejecting this response because:
GHC will not allow me to make any payment arrangements. I am willing (and able) to make a payment of more than half of the amount owed ($900. of the $1300 owed) today and the reminder of the amount owed by the end of the month. This offer was refused. GHC told me that they will not make any payment arrangements. Even car finance companies will usually allow payment arrangements to be made. The fact that I did not receive any notice (a simple email would suffice) and the fact that GHC is not flexible with their customers who are paying an insane amount of $$ for lousy service to only be treated like a number is borderline criminal! I am not even allowed to get in touch with any supervisors in the billing department to appeal who make the decisions. I'm only allowed to speak with customer service (low level workers).
This is beyond shoddy business practices and I have also reported these infractions to the State of Washington Insurance Commissioner's office.
Sincerely,[redacted]

I am writing in response to your July 7, 2017 inquiry on behalf of [redacted] received by KaiserFoundation Health Plan of Washington.We understand Mr. [redacted] submitted a complaint regarding the cost of his eye exam and believes thecost of the examination is not appropriate. He also indicated...

he submitted a complaint to the WashingtonOffice of Insurance Commission which is still under review as of the time of this complaint. We apologizefor the negative experience Mr. [redacted] has encountered with this situation.Mr. [redacted] indicates that the cost of the eye exam is too high for an in-network provider and is not in linewith the market rate. It was determined that the charges were correct and Mr. [redacted] was advised thecost of services applied to his annual deductible. Mr. [redacted]’s Optical benefit allows one routine eyeexam and refraction once every twelve months.Kaiser Permanente’s pricing is approved by the Kaiser Permanente Health Care Services PricingCommittee. Based on the set guidelines prices may decrease, increase, or remain the same.There are providers and locations, which may only offer refractive services and therefore have a differentprice structure. Kaiser Permanente’s optometry and ophthalmology specialists offer a range of medicaland treatment services as part of these comprehensive eye exams.The fee estimate link that Mr. [redacted] referenced is for Kaiser Permanente Northwest in Oregon andsouthern Washington. Although we have a similar name, Kaiser Foundation Health Plan of Washington,we are identified as different regions and are subject to regional pricing.Thank you again for taking the time to bring this matter to our attention. Should you have any furtherquestions feel free to call me at [redacted].Sincerely,Juanita S[redacted]Health Plan Administration

Please see attachment for Revdex.com response
I am writing in response to your July 21, 2016 inquiry on behalf of Mr. [redacted], received by Group Health Cooperative. We understand Mr. [redacted] expresses frustration in regards to his care received and the  timeliness. Upon 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 encountered. 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].

Please see attachment
 January 11, 2017Attn: [redacted] Revdex.comRe: Consumer: [redacted]  ID Number: [redacted]              Revdex.com Number: [redacted] Dear Mr. [redacted]:I am writing in response to your January 2, 2017...

inquiry on behalf of Ms. [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 concerns. At 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 attention. If you have any questions regarding this matter, you may reach me at 206-630-1573. Sincerely, Rebecca H** Health Plan Administration

I am writing in response to your March 2, 2017 inquiry on behalf of Ms. [redacted] received byKaiser Permanente.We apologize for the negative experience Ms. [redacted] may have encountered for her naturopathicservices. We apologize for any inconvenience this may have caused.A review of Ms. [redacted]’s...

enrollment confirms the following details;• On August 30, 2016 an election form was received under special election period allowancefor permanent residence move.• The election form indication the Optimal plan as the chosen plan and completed effective forSeptember 1, 2016.• On October 3, 2016 additional election form for the Essential plan was received andcompleted for effective date November 1, 2016.• On October 4, 2016 two additional election forms were received and same day contact to themember confirmed she wished to have Optimal plan also effective November 1, 2016.• On November 21, 2016 election form again received for the Essential plan.• As this was during the annual open enrollment period for renewal, this plan choice wascompleted effective January 1, 2017.• No additional election forms were received after November 21, 2016.The Optimal plan in effect for 2016 does have coverage for Naturopathy services. Visits fornaturopath services received December 2016 were covered under this plan and memberresponsibility of $10 copay.The Essential plan that became effective, January 1, 2017, does not have coverage for Naturopathservices resulting in services received January 2017 correctly denied to patient responsibility.Thank you again for taking the time to bring this to our attention. If you have any questions regardingthis matter, you may reach me at [redacted]Sincerely,Rebecca H**Health Plan Administration

Dear
Ms. [redacted]:I am writing in
response to your July 3, 2017 inquiry on behalf of Mr. [redacted] received
by Kaiser Permanente.  We understand Mr. [redacted]
submitted a complaint regarding his cost of medical services.  He states Kaiser Permanente providers refused
to advise him...

 of the cost of services
before they were performed and he is upset that his complaints related to the
service did not affect the billing he received. Mr. [redacted] is enrolled on
an Individual & Family plan; his  coverage is subject to a $7150 annual
deductible per calendar year and an out of pocket (OOP) limit of $7150.  All services, with the exception of
preventive services, are subject to the annual deductible and OOP limit. Once
these amounts have been satisfied for the calendar year, all cost shares, for
covered services, are paid by the plan. 
A review of the claims for services received in 2017 confirmed they
correctly applied to the annual deductible, and Mr. [redacted]’s preventive visit was
covered in full by the plan.  In May, Mr. [redacted] submitted
a complaint to Kaiser Permanente regarding his concerns about the cost of his
surgical visit in April 2017.  Our
investigation confirmed that Dr. Fields spoke directly to Mr. [redacted] about his billing
concerns for his procedure in April.  The
investigation of the complaint confirmed the care Mr. [redacted] received was appropriate.
A Physician and Family Medicine supervisor contacted Mr. [redacted] on May 30, 2017 to
review the medical treatment and left a detailed message with call back
information.  They also advised Mr. [redacted] he
could call back for any additional questions or concerns regarding his service
and treatment.Mr. [redacted] made several requests
through our Member Services department to complete chart review to related to
the cost of his care. The requests were completed for both Physical Therapy
visits and the surgical service received in April and confirmed that the claims
and billing for each are  correct.  Upon completion of our
investigation we did not find that Mr. [redacted] requested a fee estimate for
services prior to receiving them.  Kaiser
Permanente does offer fee estimates for patients who wish to have information
regarding the cost of services to help them plan and make financial arrangements.  Should Mr. [redacted] wish to have a fee estimate
prior to any future service, he may contact any Kaiser Permanente business office
for assistance.   While
we understand Mr. [redacted] has concerns regarding the cost of the services he
received, we find them to be correctly processed and billed according to his
coverage. Thank you for taking the time to bring this to our attention.
Should you have any further questions regarding this matter, you may reach me
at 206-630-1573. Sincerely,Rebecca H** Health Plan Administration

I am writing in response to your September 23, 2015 inquiry on behalf of Mr. [redacted] received by Group Health Cooperative.  We understand Mr. [redacted] has concerns with our billing process and the statements he received from Group Health. We apologize for the negative experience Mr. [redacted] has...

encountered. Our records indicate the contractual discount was applied to his account and the payment from [redacted] Insurance Company was administered on May 19, 2015. Evergreen Professional Recoveries (our contracted collection agency) confirmed this account in question has been reconciled and the member has a zero balance; not effecting the members credit.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].

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. [redacted]’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. [redacted]’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 me. Sincerely, [redacted]