Marshall Craig, M.D., S.C.

I recently received the above Revdex.com Complaint by US Mail. The person registering the complaint (the Patient) seems to be angry that he received invoices for $300 from my Billing Service, and because we did not determine that his insurance was Out Of Network for my office. The Patient was originally...

seen in my office for consultation 8/16/16 with complaints of 18-month gradual onset of lower back pain, possibly exacerbated by activities related to moving from Michigan to Arizona. Prior to his consultation, the Patient provided insurance information that he was on the Blue Cross Blue Shield of Arizona Medicare Advantage Plan. I have been a BCBS Provider for more than 16 years in Arizona. According to information supplied by BCBS AZ, the Patient was on a Plan with which I participated. Please see attached:This document highlights in yellow the “Exclusive Networks” that have a narrow provider base, and with which I can not participate. On the first page you can see that the Medicare Advantage Plan is “Off Exchange” (i.e., not an Obamacare Plan), is NOT highlighted in Yellow, and it was our understanding in my office that we participated in the Patient’s insurance plan, as we had been over the years.After thorough History, Physical Examination, and review of MRI studies it was determined that the Patient had a herniated disc at L5-S1 (the lowest lumbar disc), but fortunately did not have symptoms of radiculopathy (sciatica). As he had not pursued any prior treatment other than use of an over-the-counter lumbar brace, he was appropriately referred to physical therapy for lumbar rehabilitation. My practice specializes in Interventional Pain Management (involving epidural injections, etc.) which is not normally performed until a patient has failed more conservative treatment. The Patient went to Physical Therapy as recommended, and did experience some relief of pain; decreasing from at worst 8/10 on the numeric pain scale to 4/10 on his next office visit 9/20/16. The Patient was given the option to consider further conservative treatment vs. pursuing an epidural injection if he continued to experience significant pain. A plan for epidural injection was discussed with the Patient and an informed consent was obtained, so that if the Patient later decided to pursue interventional treatment he would not have to make another office visit. This is a common practice in my office to save patients both time and money; consents are valid for 30 days by Medicare Rules, and does not obligate the patient in any way (including financial) whatsoever.On 9/22/16 my Billing Service, which is a contracted 3rd Party, received information from BCBS AZ that the Patient’s claim was being denied because my office was somehow determined to NOT be a participating provider for the Patient, and that the Patient did not have Out Of Network Benefits. At this point, the Billing Service began working with the Patient and my office staff in order to try to get BCBS AZ to cover his claim. In the interim, the Patient was sent Billing Statements showing the unpaid charge of $300, and this is obviously what upset him. Unfortunately, that is the way medical billing works- the billing software will show a balance and the invoice will go out to the patient. The notes from the Billing Service (attached below) show that they contacted both BCBS AZ as well as the Patient in order to resolve the issue, and it is thanks to both the Billing Service and the Patient’s efforts that the appeal was successful:As of early January 2017 the BCBS AZ portion of the bill was paid, but just prior to that the Patient received another statement showing a balance of $375; once again I can understand the anger and frustration of the Patient regarding this, but usually a telephone explanation is all that is necessary to clear the matter. Both my office staff and the Billing Service had contacted the Patient regarding this, but unfortunately we were not able to get this across to the patient. Most of my patients understand that Medical Billing can be a confusing and arduous process, and are usually reassured that my Office and Billing Service are not going to send people to collections regarding these balances- it is extremely rare that we ever actually send a patient to collections. Nearly every time, through great effort we are able to get the insurance companies to cover a claim, as happened in this instance. I can’t help that the Billing Service is required to send out statements with balances due, and that in this instance the Patient couldn’t be reassured that these billing issues would eventually be resolved.Presently, the Patient does owe a balance of $30.00, for which he will be responsible and which will be his only out of pocket cost. This would be the case whether or not he is in Network, even in medical offices which are contracted with his plan (as we thought we were- but this is another matter we are diligently working to resolve). Medicare laws are extremely strict regarding writing off balances, as this constitutes Medicare Fraud and would subject me to penalties. I hope the Patient will understand.-Marshall C[redacted], MD