Oral-Facial Surgery Associates, P.S.C.

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
I
do not accept this responseThe dental office’s failure to do their due
diligence in ensuring they were quoting me correctly for this procedureWhile
the online member benefits for my insurance showed that 80% of anesthesia was
covered, there are guidelines across the board for *** *** in determining
whether or not anesthesia is covered for the procedure*** *** DOES NOT cover anesthesia for only four
non-impacted teeth extractionsThis is not unique to my case; it is their
guideline for all *** *** subscribersI find it hard to believe that this
office wouldn't be aware of these guidelines as *** *** is a major
insurance company and I'm sure this office deals with billing their insurance
regularlyI spoke with *** *** who advised that had the office called,
they would have been advised of the guidelines and advised that the anesthesia
would not have been covered for my procedure
Attached
you will find the *** *** Premier fee-for-service programPage 13, number
details the only instances in which anesthesia is covered by my insurance
My procedure does not meet any of the criteria and so it should not have been
excluded from my estimateHad I received a quote that included anesthesia at
my cost, I never would have elected to have the procedure done at all
As
stated in the Fees, Terms and Conditions of Service provided by the dental
office under "Insurance Pre-Estimate" it states that they would A.)
CALL my insurance company about expected benefits based on my plan type,
deductible, co-pay and maximum benefit, or, B.) File a WRITTEN pre-determination of benefits with my insurance company
Neither occurred and therefore this agreement cannot be upheldThey merely
checked online which did not provide the detailed information necessary to
quote my procedure accuratelyWhen I signed this agreement, it was with the
assumption that they had done one of the two scenarios provided in that
agreement for determining a pre-estimate which is what I signed and agreed toWhile I can understand that an
estimate can be off by a marginal amount on occasion, it is a blatant failure
to do a job properly when an estimate is off by a couple hundred dollarsIt is
a scamI inquired with *** *** who confirmed that NO written
pre-determination was filed with my insurance as stated would occur in the
dental office’s conditions of service agreement
The
criteria given as cause for a varying estimate, “…could vary from the actual
benefit paid based on your eligibility at the time of service, benefits used
with other dental providers, incomplete information or incorrect information
about the services you require…” none of these instances apply to meThere
were no issues with my insurance, coverage or informationThe only incorrect
information about the services I required was on the part of the dental office
and their failure to adhere to their own conditions of service agreementI
should not be made to pay for that mistake.
Since the dental
office failed to adhere to their own conditions of service by failing to either
call my insurance to regarding expected
benefits or file a written pre-determination with my insurance, my original
request of a full refund of ALL
outstanding balances owed and paid thus far through the payment plan, as well
as any associated fees, still standsIf the dental office does not agree with
this, I will be seeking legal advice as this is a violation of the agreement
that was signed by both me and a representative of that office
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
This response is not sufficient. Everything I stated was accurate and I personally called [redacted] and spoke to a rep that was able to tell me within 5 minutes that my procedure with anaesthesia  would not be covered. The business has failed to explain why they did not hold up their end of the agreement that was signed. I signed an agreement that I would receive an estimate that was provided by either CALLING my insurance or FILING a WRITTEN claim to obtain as estimate. The office failed to do both as written in their agreement. How am I to be held to an agreement in which the terms I agreed to were not honored. By failing to uphold their end of the agreement, the agreement cannot be valid. I did not agree to pay an estimate pulled from the internet. It was insanely inaccurate and the result of someone failing to do their job appropriately in that office. So long as this goes unresolved I ask that I not be sent to collections. The only reason I set up a payment plan to begin with was because I fought with this office for a year about the ridiculous misestimate I was given. The misestimate was intentional given that it is plainly written in the agreement as to how an estimate is to be obtained. If the estimate was not obtained by those conditions then the payment of such estimate does not apply. This office scammed me out of $400, knowingly did not honor their agreement, knowingly did not obtain the estimate the way they assured me they would and misrepresented the way they do business. This is not a trustworthy establishment and I want my money back. I will be seeking legal advice regarding this matter as this business violated their own agreement and are attempting to take me for $400 and threaten me with collections. I did NOT sign an agreement committing to pay an estimate obtained through an internet page. I agreed to pay an estimate obtained by phone for written claim to my insurance carrier. Estimates do not simply "vary" by hundreds of dollars. This was on interoffice error and I am being made to pay for it which is unethical and in the realms of legal binding contract/agreement, illegal. 
Regards,
[redacted]

Revdex.com1 E. 4th Street, Suite 600 Cincinnati, Ohio 45202RE: ID# [redacted]I am writing in response to complainants’ letter dated October 21, 2015. There are two issues with the patients’ response. First, there are a variety of inaccuracies stated regarding the payment of insurance claims. Second, she is trying to avoid payment based on our contract entitled "Fees, Terms and Conditions of Service. However, she signed the contract thus agreeing to the terms that states a pre-estimate is never guaranteed. The patient has made five payments on her outstanding balance. . I have included a copy for your reference (Exhibit A). First, Ms. [redacted] made a variety of inaccurate statements regarding insurance claims in hcr response letter. At Oral facial Surgery Associates, we do understand that insurance payments are a complex issue and difficult for a layperson to understand the exact procedures in which a physician's office files a claim. With that being said, Ms. [redacted] is incorrect that "had the office called, they would have been advised of the - guidelines." It is common practice in dealing with [redacted] to be referred to the website by the [redacted] Representative over the telephone. The insurance coverage sheet printed from [redacted]'s website is attached as Exhibit B. As you can see by this attachment Ms. [redacted] benefits were printed up again on October 20, 2015 and it still states general anesthesia is paid at 80%. As stated by any representative of any insurance company, they do not guarantee coverage when obtaining estimated benefits. They cannot and will not guarantee that a claim will be paid or what will be paid until the claim is actually filed.In addition, Ms. [redacted] states that "there arc guidelines across the board for [redacted] in determining whether or not anesthesia is covered for a procedure." However, this is inaccurate. I have enclosed several explanations of benefits from [redacted] (Exhibit C). These provide proof that [redacted] is not across the board when paying for anesthesia. As you can see we get payment for anesthesia many times with fewer extractions than this patient had. The differences are the results of the way the individual plan is written.Second, Ms. [redacted] signed the contract entitled, "Fees, Terms and Conditions of Service" and is attempting to avoid payment based on this contractual agreement (Exhibit A). However, the contract states that "pre-estimates are estimates only and could vary from the actual benefit paid. The estimate given to Ms. [redacted] varied from the final bill due to incomplete information received from her insurance company. The insurance company provided the information we used for the estimate and this information provided by the insurance company was incomplete information. Situations such as these do occasionally arise and as a result we have our patients sign the contract entitled, "Fees, Terms and Conditions of Service" to help our patients understand that we can only provide estimates, and that the insurance pre-estimate is never guaranteed. We contact patient’s insurance company for information on benefits as a courtesy to our patients. We try to give patients an ideal of out of pocket expenses with the information we receive. This is never exact.Ms. [redacted] has made five payments on her account. She currently owes $149.37 and has paid a total $300. We have been extremely flexible with Ms. [redacted] regarding her delinquency and have offered to set up payment arrangements on her account; however a payment has not been made since October. We do request that Ms. [redacted] contact our office promptly to avoid any Collections effort from an outside company.Feel free to call my office at your convenience to discuss any remaining questions regarding this matter.Thank you,Yvonne R[redacted] Practice Manager Oral Facial Surgery Associates 330 Thomas More Parkway, Suite 101 Crestview Hills, KY 41017###-###-####[redacted]

Tuesday, October 20, 2015Revdex.com 1.E. 4", Suite 600 Cincinnati, Ohio 45202Re: ID [redacted]To whom It May Concern;I am writing in response to correspondence from your office in regards to a patient’s complaint. The patient was seen in our office for an initial consultation on 3/12/14. At that time an...

exam and x-ray were done and insurance was checked on line as is protocol in our office. We found on line that this patients plan with [redacted] covered this procedure at 80% with a $50.00 deductible and a $1500.00 annual maximum; also that she had her full benefit at that time. She was given an amount to pay on the day of surgery based on these findings and was told this was only an estimate and she would be billed for any balances. As all patients in our office she signed a financial agreement stating the fees and that this is an estimate. We work very hard to help our patients understand that checking benefits is never a guarantee of payment.When the surgery claim was paid and the anesthesia was denied we spoke with the patient and filed an appeal for her with the insurance company, The appeal was denied, therefore the patient was billed the balance. After several statements were sent to the patient, she called and was advised we were happy to set up a payment plan in-house.Please let me know if I can provide any further information.enc: copy of signed financial agreement & screen shot of current on line benefitsRegards,Yvonne R[redacted] Practice ManagerOral Facial Surgery Associates [redacted]Phone: [redacted]