Newport-Mesa Audiology Balance And Ear Institute

Revdex.com: I have reviewed the? response made by the business in reference to complaint ID [redacted] , and have determined that this proposed action would not resolve my complaint.? For your reference, details of the offer I reviewed appear below 1.Newport Mesa told that they were in network and the hearing test was covered by my insurance 80/20.? It was never a "maybe" your insurance will pay thisNewport Mesa called me multiple times after we considered not doing the hearing test due to cost to assure us that we would only owe 20% of the negotiated rate of $The only reason they were charging us the $per child up front is because we had not hit our deductible yet.? It's been months, we hit our individual & family deductibles months ago and we have not received a refund for the 80% they told me was covered by insurance.? Bottom line Newport Mesa told us we would owe 20% of $(kids @ $650) after we hit our deductible.? We would have NEVER paid $for a hearing test.? We have done a hearing test at CHOC ENT and paid less than $They never told us that the quote they gave me was a maybe.? They told me the negotiated rate with your insurance is $per child and your benefits are 80/after the deductible is reached.5.? If the only reason they charged us the entire negotiated rate up front was not hitting the deductible, they should refund us the 80% ($1040) now that we have hit the deductible.? We paid then $months ago and $have been applied to our out of pocket maximum or deductible.? I don't understand why we have received notification from our insurance, but they have not.? We have an EOB for each child date issues 9/29/(before I filed the original complaintPlease see attached PDFThey have no motivation to get insurance to pay anything because they already have our money for the total cost.8.? Why would they "verify" benefits that may or may not apply?? That basically means they didn't verify anything.? They told me they were in network and our insurance is saying they are NOT.? Newport Mesa know who they have contracts with.9.? I was referred to Newport Mesa for a hearing test.? As a consumer I do not have access to ICD codes, how to tell if a test is "medically necessary", or if there are restrictions as to the type of practitioner that is allowed to perform exams....? All I want is for Newport Mesa to honor their quote.? We would owe 20% of $per child.? Please refund my money Regards, [redacted] ***

[redacted] Dear Ms [redacted] :Thank you again for your letter dated October 19, 2015; please consider this our responsePlease be advised that we have formulated an appeal based on the copies of the patient's Explanation of Benefits attached to your letter referenced aboveWe hope the ***'s insurance carrier will reconsider their denial and pay for the services rendered to their children respectively.In direct response the “message from consumer:”We are In NetworkThe ***'s insurance carrier is denying the charges based on medicalnecessity, not based on an In or Out of network situationWe did, in fact, contact the ***'s regarding the costThis fact is not in disputeHowever, we never advised them that they would only be responsible for 20% of the negotiated rate of $We were very up front and advised them that the Out of Pocket cost for this type of appointment was, in fact, $650.00, per childWhile we realize that it has been Eight (8) months, the claims were just processed by their insurance carrier (please see the explanation of benefits issue date of September 29, 2015)We have no control over thisIn addition, the patient's did not just receive a basic “hearing test"They received a Diagnostic Pediatric Audiological EvaluationThis was an evaluation, which is much more detailed than any “hearing test"We are an Audiological Institute with over year's experience; we do not do just simple hearing testsPlease see response number Please see response number Please see response number We have every motivation, as this is our reputationWe verify each and every patient's benefits that have an appointment at our instituteThe benefits that we quote are not a guarantee of payment, this is just what the expectation may or may not beAs we stated, to the ***s, the cost of the appointment is $and this fact is not in disputeThe ***'s Insurance Company are the ones who determined what is medically necessary and whatis notWe have sent an appeal in hopes that they will reconsider their decision.We hope that this answers the ***'s questionsWe are hopeful that the insurance company will reconsider their decision and reprocess the claims for paymentWe have done our due diligence in providing them with the medical documentation for all of the services that were provided to the ***'s children.If you have any questions, please contact our office

Re: Complaint ID: [redacted] ***Dear Ms [redacted] :This letter is in response to the above-mentioned complaint, Please be advised that we take these matters very seriouslyIn the case of Mrs***'s twins, as of the date of this letter, we have not received any notification from the patient's insurance carrier, with respect to any denial or any communication thereofIn the case that the claims were denied for medical necessity, in our course of business, we would formulate an appeal and send it to the appropriate department of the insurance carrier.As a matter of protocol, we verify benefits for each and every patient that we see at our InstituteWe advise the patient via phone prior to their appointment of their benefits and if there will be an out of pocket (OOP) cost, if anyIn this case, we advise Mrs [redacted] that because they had such a high deductible, the OOP cost of the appointment per child would be $650.00, which is the cost of the appointmentThe patient paid the OOP cost at the time of the appointmentThe benefits quoted the patient prior to the appointment were that their insurance company would pay 80% and they would be responsible for a 20% co-insurance, once the deductible has been metHowever, as it is with all verification of benefits, the insurance carrier's all state that when we verify benefits, "A quote of benefits and/or authorization does not guarantee payment or verify eligibilityPayment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service",Once we receive the Explanation of Benefits from the patient's insurance carrier, we will formulate an appeal and send it to the patient's carrierThey will respond and then we will make the appropriate financial reimbursement, if any; based on what their decision isThere is no “bait and switch"Pursuant to our protocol, we advise our patients of the situation prior to providing services.If you have any questions, please contact our Director of Operations, Mr [redacted] Thank you for yourMedical DirectorHTM;hsNewport-Mcsa Audiology Balance and Ear Institute l” a g c |

[redacted] ***Dear Ms [redacted] :Thank you again for your letter dated October 19, 2015; please consider this our responsePlease be advised that we have formulated an appeal based on the copies of the patient's Explanation of Benefits attached to your letter referenced aboveWe hope the ***'s insurance carrier will reconsider their denial and pay for the services rendered to their children respectively.In direct response the “message from consumer:”We are In NetworkThe ***'s insurance carrier is denying the charges based on medicalnecessity, not based on an In or Out of network situationWe did, in fact, contact the ***'s regarding the costThis fact is not in disputeHowever, we never advised them that they would only be responsible for 20% of the negotiated rate of $We were very up front and advised them that the Out of Pocket cost for this type of appointment was, in fact, $650.00, per childWhile we realize that it has been Eight (8) months, the claims were just processed by their insurance carrier (please see the explanation of benefits issue date of September 29, 2015)We have no control over thisIn addition, the patient's did not just receive a basic “hearing test"They received a Diagnostic Pediatric Audiological EvaluationThis was an evaluation, which is much more detailed than any “hearing test"We are an Audiological Institute with over year's experience; we do not do just simple hearing testsPlease see response number Please see response number Please see response number We have every motivation, as this is our reputationWe verify each and every patient's benefits that have an appointment at our instituteThe benefits that we quote are not a guarantee of payment, this is just what the expectation may or may not beAs we stated, to the ***s, the cost of the appointment is $and this fact is not in disputeThe ***'s Insurance Company are the ones who determined what is medically necessary and whatis notWe have sent an appeal in hopes that they will reconsider their decision.We hope that this answers the ***'s questionsWe are hopeful that the insurance company will reconsider their decision and reprocess the claims for paymentWe have done our due diligence in providing them with the medical documentation for all of the services that were provided to the ***'s children.If you have any questions, please contact our office

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below
1.Newport Mesa told that they were in network and the hearing test was covered by my insurance 80/20. It was never a "maybe" your insurance will pay thisNewport Mesa called me multiple times after we considered not doing the hearing test due to cost to assure us that we would only owe 20% of the negotiated rate of $The only reason they were charging us the $per child up front is because we had not hit our deductible yet. It's been months, we hit our individual & family deductibles months ago and we have not received a refund for the 80% they told me was covered by insurance. Bottom line Newport Mesa told us we would owe 20% of $(kids @ $650) after we hit our deductible. We would have NEVER paid $for a hearing test. We have done a hearing test at CHOC ENT and paid less than $They never told us that the quote they gave me was a maybe. They told me the negotiated rate with your insurance is $per child and your benefits are 80/after the deductible is reached.5. If the only reason they charged us the entire negotiated rate up front was not hitting the deductible, they should refund us the 80% ($1040) now that we have hit the deductible. We paid then $months ago and $have been applied to our out of pocket maximum or deductible. I don't understand why we have received notification from our insurance, but they have not. We have an EOB for each child date issues 9/29/(before I filed the original complaintPlease see attached PDFThey have no motivation to get insurance to pay anything because they already have our money for the total cost.8. Why would they "verify" benefits that may or may not apply? That basically means they didn't verify anything. They told me they were in network and our insurance is saying they are NOT. Newport Mesa know who they have contracts with.9. I was referred to Newport Mesa for a hearing test. As a consumer I do not have access to ICD codes, how to tell if a test is "medically necessary", or if there are restrictions as to the type of practitioner that is allowed to perform exams.... All I want is for Newport Mesa to honor their quote. We would owe 20% of $per child. Please refund my money
Regards,
*** ***

*** ***Dear Ms***:Thank you again for your letter dated October 19, 2015; please consider this our responsePlease be advised that we have formulated an appeal based on the copies of the patient's Explanation of Benefits attached to your letter referenced aboveWe hope the ***'s insurance carrier will reconsider their denial and pay for the services rendered to their children respectively.In direct response the “message from consumer:”We are In NetworkThe ***'s insurance carrier is denying the charges based on medicalnecessity, not based on an In or Out of network situationWe did, in fact, contact the ***'s regarding the costThis fact is not in disputeHowever, we never advised them that they would only be responsible for 20% of the negotiated rate of $We were very up front and advised them that the Out of Pocket cost for this type of appointment was, in fact, $650.00, per childWhile we realize that it has been Eight (8) months, the claims were just processed by their insurance carrier (please see the explanation of benefits issue date of September 29, 2015)We have no control over thisIn addition, the patient's did not just receive a basic “hearing test"They received a Diagnostic Pediatric Audiological EvaluationThis was an evaluation, which is much more detailed than any “hearing test"We are an Audiological Institute with over year's experience; we do not do just simple hearing testsPlease see response number Please see response number Please see response number We have every motivation, as this is our reputationWe verify each and every patient's benefits that have an appointment at our instituteThe benefits that we quote are not a guarantee of payment, this is just what the expectation may or may not beAs we stated, to the ***s, the cost of the appointment is $and this fact is not in disputeThe ***'s Insurance Company are the ones who determined what is medically necessary and whatis notWe have sent an appeal in hopes that they will reconsider their decision.We hope that this answers the ***'s questionsWe are hopeful that the insurance company will reconsider their decision and reprocess the claims for paymentWe have done our due diligence in providing them with the medical documentation for all of the services that were provided to the ***'s children.If you have any questions, please contact our office

Re: Complaint ID: *** ***Dear Ms***:This letter is in response to the above-mentioned complaint, Please be advised that we take these matters very seriouslyIn the case of Mrs***'s twins, as of the date of this letter, we have not received any notification from the
patient's insurance carrier, with respect to any denial or any communication thereofIn the case that the claims were denied for medical necessity, in our course of business, we would formulate an appeal and send it to the appropriate department of the insurance carrier.As a matter of protocol, we verify benefits for each and every patient that we see at our InstituteWe advise the patient via phone prior to their appointment of their benefits and if there will be an out of pocket (OOP) cost, if anyIn this case, we advise Mrs*** that because they had such a high deductible, the OOP cost of the appointment per child would be $650.00, which is the cost of the appointmentThe patient paid the OOP cost at the time of the appointmentThe benefits quoted the patient prior to the appointment were that their insurance company would pay 80% and they would be responsible for a 20% co-insurance, once the deductible has been metHowever, as it is with all verification of benefits, the insurance carrier's all state that when we verify benefits, "A quote of benefits and/or authorization does not guarantee payment or verify eligibilityPayment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service",Once we receive the Explanation of Benefits from the patient's insurance carrier, we will formulate an appeal and send it to the patient's carrierThey will respond and then we will make the appropriate financial reimbursement, if any; based on what their decision isThere is no “bait and switch"Pursuant to our protocol, we advise our patients of the situation prior to providing services.If you have any questions, please contact our Director of Operations, Mr*** ***Thank you for yourMedical DirectorHTM;hsNewport-Mcsa Audiology Balance and Ear Institute l” a g c | ?

Re: Complaint ID: [redacted]Dear Ms. [redacted]:This letter is in response to the above-mentioned complaint, Please be advised that we take these matters very seriously. In the case of Mrs. [redacted]'s twins, as of the date of this letter, we have not received any notification from the...

patient's insurance carrier, with respect to any denial or any communication thereof. In the case that the claims were denied for medical necessity, in our normal course of business, we would formulate an appeal and send it to the appropriate department of the insurance carrier.As a matter of protocol, we verify benefits for each and every patient that we see at our Institute. We advise the patient via phone prior to their appointment of their benefits and if there will be an out of pocket (OOP) cost, if any. In this case, we advise Mrs. [redacted] that because they had such a high deductible, the OOP cost of the appointment per child would be $650.00, which is the cost of the appointment. The patient paid the OOP cost at the time of the appointment. The benefits quoted the patient prior to the appointment were that their insurance company would pay 80% and they would be responsible for a 20% co-insurance, once the deductible has been met. However, as it is with all verification of benefits, the insurance carrier's all state that when we verify benefits, "A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service",Once we receive the Explanation of Benefits from the patient's insurance carrier, we will formulate an appeal and send it to the patient's carrier. They will respond and then we will make the appropriate financial reimbursement, if any; based on what their decision is. There is no “bait and switch". Pursuant to our protocol, we advise our patients of the situation prior to providing services.If you have any questions, please contact our Director of Operations, Mr. [redacted]. Thank you for yourMedical DirectorHTM;hsNewport-Mcsa Audiology Balance and Ear Institute l” a g c | 2

[redacted]Dear Ms. [redacted]:Thank you again for your letter dated October 19, 2015; please consider this our response. Please be advised that we have formulated an appeal based on the copies of the patient's Explanation of Benefits attached to your letter referenced above. We hope the [redacted]'s insurance carrier will reconsider their denial and pay for the services rendered to their children respectively.In direct response the “message from consumer:”1. We are In Network. The [redacted]'s insurance carrier is denying the charges based on medicalnecessity, not based on an In or Out of network situation. 2. We did, in fact, contact the [redacted]'s regarding the cost. This fact is not in dispute. However, we never advised them that they would only be responsible for 20% of the negotiated rate of $650.00. We were very up front and advised them that the Out of Pocket cost for this type of appointment was, in fact, $650.00, per child. 3. While we realize that it has been Eight (8) months, the claims were just processed by their insurance carrier (please see the explanation of benefits issue date of September 29, 2015). We have no control over this. In addition, the patient's did not just receive a basic “hearing test". They received a Diagnostic Pediatric Audiological Evaluation. This was an evaluation, which is much more detailed than any normal “hearing test". We are an Audiological Institute with over 35 year's experience; we do not do just simple hearing tests. Please see response number 2. Please see response number 2. Please see response number 3. We have every motivation, as this is our reputation.8. We verify each and every patient's benefits that have an appointment at our institute. The benefits that we quote are not a guarantee of payment, this is just what the expectation may or may not be. As we stated, to the [redacted]s, the cost of the appointment is $650.00 and this fact is not in dispute.9. The [redacted]'s Insurance Company are the ones who determined what is medically necessary and whatis not. We have sent an appeal in hopes that they will reconsider their decision.We hope that this answers the [redacted]'s questions. We are hopeful that the insurance company will reconsider their decision and reprocess the claims for payment. We have done our due diligence in providing them with the medical documentation for all of the services that were provided to the [redacted]'s children.If you have any questions, please contact our office.

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
1.Newport Mesa told that they were in network and the hearing test was covered by my insurance 80/20.  It was never a "maybe" your insurance will pay this.2. Newport Mesa called me multiple times after we considered not doing the hearing test due to cost to assure us that we would only owe 20% of the negotiated rate of $650. The only reason they were charging us the $650 per child up front is because we had not hit our deductible yet.  3. It's been 8 months, we hit our individual & family deductibles months ago and we have not received a refund for the 80% they told me was covered by insurance.  Bottom line --> Newport Mesa told us we would owe 20% of $1300 (2 kids @ $650) after we hit our deductible.  We would have NEVER paid $1300 for a hearing test.  We have done a hearing test at CHOC ENT and paid less than $100.4. They never told us that the quote they gave me was a maybe.  They told me the negotiated rate with your insurance is $650 per child and your benefits are 80/20 after the deductible is reached.5.  If the only reason they charged us the entire negotiated rate up front was not hitting the deductible, they should refund us the 80% ($1040) now that we have hit the deductible.  We paid then $1300 8 months ago and $0 have been applied to our out of pocket maximum or deductible.  6. I don't understand why we have received notification from our insurance, but they have not.  We have an EOB for each child date issues 9/29/2015 (before I filed the original complaint. Please see attached PDF.7. They have no motivation to get insurance to pay anything because they already have our money for the total cost.8.  Why would they "verify" benefits that may or may not apply?  That basically means they didn't verify anything.  They told me they were in network and our insurance is saying they are NOT.  Newport Mesa know who they have contracts with.9.  I was referred to Newport Mesa for a hearing test.  As a consumer I do not have access to ICD codes, how to tell if a test is "medically necessary", or if there are restrictions as to the type of practitioner that is allowed to perform exams....  All I want is for Newport Mesa to honor their quote.  We would owe 20% of $650 per child.  Please refund my money.
Regards,
[redacted]