Landmark Healthcare, Inc.

Date: November 18, 2015Revdex.com Beacon Blvd.West Sacramento, CA 95691Attn.: *** ***RE: Revdex.com Case #***I am writing in response to your complaint, forwarded by the Revdex.com of West Sacramento, CA, and received in this office November 11, 2015, concerning
difficulties with the clinical certification process. Landmark Healthcare, Incd/b/a eviCore healthcare MSK Services (“eviCore”), is very concerned with member satisfaction and understanding of the clinical certification process and appreciates your comments. The policies and procedures that govern eviCore’s Clinical Certification Program are subject to the quality standards established by external regulatory bodies such as the Centers for Medicare and Medicaid Services (CMS), the Department of Health, the National Committee for Quality Assurance (NCQA) and the American Accreditation HealthCare Commission (URAC)eviCore staff members are rigorously trained and regularly monitored in the application of these policies. Any issues requiring remediation can be addressed globally and/or individually. Documentation of training, compliments, or complaints and any disciplinary actions are maintained for each staff member as the basis for regular performance evaluations and improvement effortsThe case records for this member were reviewed by eviCore’s Director for Chiropractic Services, *** ***, DC who provided the following comments:The review of coverage according to medical necessity is fairly standard for determining insurance coverageeviCore reviews the medical necessity of requested services using Evidence-Based guidelines that are based on clinical information from textbooks, peer reviewed publications and expert opinioneviCore reviews each patient’s individual case according to the published guidelineseviCore’s clinical guidelines for the patient’s condition state that the patient should improve rapidly with chiropractic treatment, and that you should be transitioned to an exercise program consisting of spinal stabilization exercises within the first four weeks of treatmentThe guidelines also state that if the patient’s condition does not improve as expected, the patient should be transitioned to an appropriate health care provider to explore other treatment alternativesThe clinical information submitted by Dr*** indicates this patient has been treated for the same condition for over nine months. Over this period, Dr***’s records do not record significant improvement in pain or function. The notes indicate the patient has consistently received the same passive treatment on each visit (spinal manipulation to the neck, middle back, and lower back). The same exam findings are also reported on each visit (muscle spasm and restricted motion). The notes do not indicate any effort to transition the patient to an active care program consisting of spinal stabilization exercises. The clinical information submitted by Dr*** did not establish the medical necessity of ongoing chiropractic treatment. Dr***’s records did not record significant improvement in pain or function. According to eviCore’s clinical guidelines, this patient should have been referred to another provider for other treatment options. The absence of a transition to active care appears to have contributed to a treatment duration that far exceeded the expected course of treatment.I hope this satisfactorily addresses the concerns this patient raised about difficulties encountered with the clinical certification process. The complaint will be presented to the appropriate eviCore Committees and will be included in our quality management analysis of the eviCore Care Management Unit (CMU). Thank you for bringing your experience to my attention. If you need any further information or clarification, feel free to contact me directly at *** extension ***. Sincerely,*** ***SrDirector Clinical Operational Compliance and Delegation OversighteviCore healthcare

I am rejecting this response because:Much of what Landmark Healthcare (via eviCore healthcare) states in their response is completely false.  This is evidenced by the attached documents.  These attached documents are Landmark Healthcare's (eviCore's) own forms as filled out by Dr. [redacted].For example, Landmark (eviCore healthcare) states in their response that "The notes do not indicate any effort to transition the patient to an active care program consisting of spinal stabilization exercises".  However, as clearly highlighted in yellow on the attached forms, Patient Home Care has always been recommended by my Dr. [redacted].  Therefore, their response is simply untrue.I have X-Rays from my Chiropractor that prove I need this Chiropractic healthcare. I have digital scanned progress exams from my Chiropractor that prove I need this Chiropractic healthcare. The only one that seems to think otherwise is Landmark Healthcare (eviCore, who believes they know better than a doctor whether or not I need healthcare.  Their decision to reject my need of this care is solely for the purpose to maximize their profits by denying access that I pay for with my premiums every month.Landmark needs to go back to when I met my deductible, early this year, and reimburse me for all those appointments for which I was entitled to pay only a $15 copay.
I want this complaint to go on record so that everyone else who checks on this firm, Landmark Healthcare, along with any and all their affiliates (eviCore), and including [redacted], realize that they are dealing with a scam outfit, that claims to offer great services, such as this low-cost $15 copay once the deductible is met, but then refuses to cover those offered claims per their agreements when the time comes for them to comply with their end of the agreement.

Review: Landmark Healthcare has repeatedly denied physical therapy visits for our 16 year old daughter who tore her ACL and had surgery this October. Our surgeon has required two PT visits per week minimum. Landmark has only approved an allotment of one per week. They have repeatedly lied to us and to our PT about reasons for denying these PT visits. Our insurance allows up to 60 PT visits per year. We are in absolutely no danger of running out of visits yet they are denied to us.Desired Settlement: Landmark needs to immediately allow us access to the full PT visits which we paid for, and which the surgeon required. Landmark needs to immediately refund us for the PT visits they have denied us in the past. Landmark needs to issue an immediate apology to us and to the Physical Therapist office and copy [redacted] for the lies they have told us the past two months.

Business

Response:

The complaint alleges that prior authorization requests for Physical Therapy have been repeatedly denied. The review of this members records indicates that there is no history of denial of care. Review of coverage according to medical necessity is fairly standard for determining insurance coverage. Landmark reviews the medical necessity of requested services using Evidence-Based Guidelines that are based on clinical information from textbooks, peer reviewed publications, and expert opinion. The guidelines are published on both the [redacted] and Landmark web sites. Landmark reviews each patient’s individual case according to the published guidelines. The medically necessary frequency of treatment is determined by the severity of the patient’s condition. The medical necessity of ongoing treatment is established when the patient’s pain and/or function improves significantly with an initial course of treatment. If the patient’s condition improves significantly, the frequency of treatment should decrease. If a patient’s condition stops improving, the patient is considered to have reached a maximum level of improvement; and ongoing care is not considered medically necessary. The member’s case records have been reviewed by Landmark’s Director for Therapy Services, [redacted] PT, MS, DPT who has provided the following comments: The member is a 16 year old referred for physical therapy following surgery on 10/3/14 to repair a torn anterior cruciate ligament. Therapy was initiated on 10/7/14 and one visit was authorized to cover this visit. On 10/23/14, the provider ([redacted]) submitted a request for additional therapy. The provider requested a start date of 10/30/14. Eight visits were approved for use from 10/30/14 to 11/29/14 with the expectation that visits would be spread throughout the authorized period of time. The member presented as expected post-operatively with complaints of pain, loss of knee flexion, weakness, and limitations in her functional activities. On 11/13/14, the provider submitted another request for physical therapy with a requested start date of 11/20/14. This request overlapped the existing authorization, which covered the period beginning 10/30/14 and ending 11/29/14. The information provided by the therapist demonstrated improvement in motion, strength, and function but deficits remained. The reviewer authorized 2 additional visits to be used from 11/20/14 through 11/29/14 to avoid a gap in care. A total of 10 visits were authorized for use from 10/30/14 through 11/29/14. On 12/2/14, the therapist submitted a request for additional therapy with a requested start date of 12/4/14. Four visits were authorized for use from 12/4/14 through 12/31/14. The information provided by the therapist demonstrated continued improvement. Pain was reported to be 2/10 (mild), motion was functional, and strength ranged from 3 to 5/5 where 5 is normal strength. Function was improving but the member continued to report problems sitting, standing, walking, and going up/down stairs.

Consumer

Response:

I am rejecting this response because:It is full of lies and deceit. Based on the mis-management of this case, the constant denial of services and the lies about why services were denied I can only attest that Landmark is a horrible representation of [redacted]. Landmark has repeatedly said to our Physical Therapist that she can not even apply for additional visits until after certain dates, in writing. I have copies of all of these letters. BCN states that they (their own sub contractor)can not do this, yet they continue to do so. I have ALL of the paperwork to support our case, including the Landmark service denied letters in response to our Physical Therapist service request letters. I am attaching only the cover sheet as it is some 10 pages of documents. Of course Landmark does not label their letters "service denied", but nonetheless they deny services which we have paid for, and which our surgeon and our PT have demonstrated that our daughter needs to properly recover. Landmark is clearly not in the business of "managed care". Rather they are in the business of hoarding BCN money, denying services required by medical professionals who have personally evaluated the actual patient. They come across as a cheap, sleazy, used car salesman, looking to steal the next dollar at any cost.What an absolute dreadful representation of Blue Cross.

Business

Response:

This letter is in follow up to our initial response on December 11, 2014, and the complainants’ rejection of our review on December 19, 2014. As stated in our initial response, Landmark performed a review of all clinical documentation for the complainants’ daughter, and there have been no medical necessity denials for services made by Landmark for this member. Landmark has been delegated the process of medical necessity reviews for BCN only. Landmark does not process or pay claims for BCN. This function is performed by the health plan. To this point, our response can only address the medical necessity review process. Any complaints or investigation into the denial of a claim submitted to BCN should be addressed with the health plan. Review of coverage according to medical necessity is fairly standard for determining insurance coverage. Landmark reviews the medical necessity of requested services using Evidence-Based Guidelines that are based on clinical information from textbooks, peer reviewed publications, and expert opinion. The guidelines are published on both the BCN and Landmark web sites. Landmark reviews each patient’s individual case according to the published guidelines. The medically necessary frequency of treatment is determined by the severity of the patient’s condition. The medical necessity of ongoing treatment is established when the patient’s pain and/or function improves significantly with an initial course of treatment. If the patient’s condition improves significantly, the frequency of treatment should decrease. If a patient’s condition stops improving, the patient is considered to have reached a maximum level of improvement; and ongoing care is not considered medically necessary. To address the complainants’ desired resolution: 1. Landmark needs to immediately allow us access to the full PT visits which we paid for and which the surgeon required. a. Landmark response: All requests for a medical necessity review of services for this member have been completed and approved. Landmark has not issued any medical necessity denial of services for this member. 2. Landmark needs to immediately refund us for the PT visits they have denied us in the past. a. Landmark response: Landmark has not issued any medical necessity denial of services for this member. 3. Landmark needs to issue an immediate apology to us and to the Physical Therapist office and copy Blue Cross for the lies they have told us the past two months. a. Landmark response: Landmark is concerned with member and provider satisfaction with the medical necessity review process. The company apologies for any misunderstanding by the complainant, about the role of Landmark, in the Physical Therapy benefit review process. As stated above and in our previous response, the company is only responsible for reviewing requests from providers for medical necessity. This process was completed for the complainants’ daughter, and no denials of requests have been issued. If the complainant has claim denials, he should have those investigated by BCN. Landmark will provide a copy of this response and the original response to BCN for review. Please let us know if we may be of further assistance.

Consumer

Response:

I am rejecting this response because:Landmark Healthcare repeatedly has lied about why they are denying physical therapy visits for our daughter's recovery from ACL knee surgery.

Review: I purchased a healthcare plan, a portion of which is outsourced to Landmark Healthcare. Included in the outsourced portion is my Chiropractic Medical care, which is handled through Landmark Healthcare.Ever since I have met my high deductible per my plan, my Chiropractic appointments are supposed to cost me $15 per appointment per my contract that I pay for every month. However, since I have met that high deductible this calendar year, Landmark has rejected almost every single appointment to my Chiropractor. Therefore, I am paying more than double what I should be paying every time I go to an appointment for adjustments.The reason that Landmark is rejecting my Chiropractic care is because it is costing them more money. I have never before had a problem being covered before when I had CDPHP healthcare. But now that the managed care firm, Landmark Healthcare, is handling my Chiropractic healthcare, they are refusing to cover me per our paid agreement.I have X-Rays from my Chiropractor that prove I need this Chiropractic healthcare. I have digital scanned progress exams from my Chiropractor that prove I need this Chiropractic healthcare. The only one that seems to think otherwise is Landmark Healthcare, who believes they know better than a doctor whether or not I need healthcare. Thats not so difficult to understand since they are obligated to pay out a portion for my Chiropractic healthcare. So why would they care about my health? They need to maximize their profits, and that occurs on the backs of those who need healthcare, for such are these deceitful workmen, disguising themselves as healthcare professionals. So uncaring, yet so greedy for ill-gotten gain.I have several phone calls into Landmark Healthcare regarding these issues. Therefore, due to the frustration, this complaint commences here. The next step is to start writing reviews online if this fails to resolve the issue once and for all.Desired Settlement: Landmark needs to go back to when I met my deductible, early this year, and reimburse me for all those appointments for which I was entitled to pay only a $15 copay.I want this complaint to go on record so that everyone else who checks on this firm, Landmark Healthcare, along with any and all their affiliates, including [redacted], realize that they are dealing with a scam outfit, that claims to offer great services, such as this low-cost $15 copay once the deductible is met, but never pay

Business

Response:

Date: November 18, 2015Revdex.com 3075 Beacon Blvd.West Sacramento, CA 95691Attn.: [redacted]RE: Revdex.com Case #[redacted]I am writing in response to your complaint, forwarded by the Revdex.com of West Sacramento, CA, and received in this office November 11, 2015, concerning difficulties with the clinical certification process. Landmark Healthcare, Inc. d/b/a eviCore healthcare MSK Services (“eviCore”), is very concerned with member satisfaction and understanding of the clinical certification process and appreciates your comments. The policies and procedures that govern eviCore’s Clinical Certification Program are subject to the quality standards established by external regulatory bodies such as the Centers for Medicare and Medicaid Services (CMS), the Department of Health, the National Committee for Quality Assurance (NCQA) and the American Accreditation HealthCare Commission (URAC). eviCore staff members are rigorously trained and regularly monitored in the application of these policies. Any issues requiring remediation can be addressed globally and/or individually. Documentation of training, compliments, or complaints and any disciplinary actions are maintained for each staff member as the basis for regular performance evaluations and improvement efforts. The case records for this member were reviewed by eviCore’s Director for Chiropractic Services, [redacted], DC who provided the following comments:The review of coverage according to medical necessity is fairly standard for determining insurance coverage. eviCore reviews the medical necessity of requested services using Evidence-Based guidelines that are based on clinical information from textbooks, peer reviewed publications and expert opinion. eviCore reviews each patient’s individual case according to the published guidelines. eviCore’s clinical guidelines for the patient’s condition state that the patient should improve rapidly with chiropractic treatment, and that you should be transitioned to an exercise program consisting of spinal stabilization exercises within the first four weeks of treatment. The guidelines also state that if the patient’s condition does not improve as expected, the patient should be transitioned to an appropriate health care provider to explore other treatment alternatives. The clinical information submitted by Dr. [redacted] indicates this patient has been treated for the same condition for over nine months. Over this period, Dr. [redacted]’s records do not record significant improvement in pain or function. The notes indicate the patient has consistently received the same passive treatment on each visit (spinal manipulation to the neck, middle back, and lower back). The same exam findings are also reported on each visit (muscle spasm and restricted motion). The notes do not indicate any effort to transition the patient to an active care program consisting of spinal stabilization exercises. The clinical information submitted by Dr. [redacted] did not establish the medical necessity of ongoing chiropractic treatment. Dr. [redacted]’s records did not record significant improvement in pain or function. According to eviCore’s clinical guidelines, this patient should have been referred to another provider for other treatment options. The absence of a transition to active care appears to have contributed to a treatment duration that far exceeded the expected course of treatment.I hope this satisfactorily addresses the concerns this patient raised about difficulties encountered with the clinical certification process. The complaint will be presented to the appropriate eviCore Committees and will be included in our quality management analysis of the eviCore Care Management Unit (CMU). Thank you for bringing your experience to my attention. If you need any further information or clarification, feel free to contact me directly at [redacted] extension [redacted]. Sincerely,[redacted]Sr. Director Clinical Operational Compliance and Delegation OversighteviCore healthcare

Consumer

Response:

I am rejecting this response because:Much of what Landmark Healthcare (via eviCore healthcare) states in their response is completely false. This is evidenced by the attached documents. These attached documents are Landmark Healthcare's (eviCore's) own forms as filled out by Dr. [redacted].For example, Landmark (eviCore healthcare) states in their response that "The notes do not indicate any effort to transition the patient to an active care program consisting of spinal stabilization exercises". However, as clearly highlighted in yellow on the attached forms, Patient Home Care has always been recommended by my Dr. [redacted]. Therefore, their response is simply untrue.I have X-Rays from my Chiropractor that prove I need this Chiropractic healthcare. I have digital scanned progress exams from my Chiropractor that prove I need this Chiropractic healthcare. The only one that seems to think otherwise is Landmark Healthcare (eviCore, who believes they know better than a doctor whether or not I need healthcare. Their decision to reject my need of this care is solely for the purpose to maximize their profits by denying access that I pay for with my premiums every month.Landmark needs to go back to when I met my deductible, early this year, and reimburse me for all those appointments for which I was entitled to pay only a $15 copay.

I want this complaint to go on record so that everyone else who checks on this firm, Landmark Healthcare, along with any and all their affiliates (eviCore), and including [redacted], realize that they are dealing with a scam outfit, that claims to offer great services, such as this low-cost $15 copay once the deductible is met, but then refuses to cover those offered claims per their agreements when the time comes for them to comply with their end of the agreement.