Orthopedic Assoc. of LI, LLP

March **, RE: [redacted] Complaint#: [redacted] This letter is written in reply to the complaint made by [redacted] regarding care received by [redacted] [redacted] was on call at Mather Hospital when [redacted] presented with an injury to his left wrist after falling from the monkey bars [redacted] examined the patient on and reviewed all information regarding this injury after which he diagnosed a [redacted] A bill was sent to the insurance company for the Emergency Room visit (***) and the [redacted] , which is coded as ***The [redacted] is considered a surgical code because it is part of the Musculosketal section of the Current Procedure Terminology (CPT) coding system [redacted] is a non participating provider as [redacted] explained and therefore all payments were sent directly to the policy holderThis is standard policy for Empire New York State InsuranceThe patient was sent check# [redacted] for $on for the Emergency Room visit and the [redacted] careThe patient followed up in our office for follow up x-rays to determine how well the [redacted] and growth plate were healing [redacted] performed one x-ray per month for months to monitor the healing processThe office billed a total of X-rays in which the insured was issued two checks directlyThe first was issued ck# [redacted] for $and the second check was issued for the last two x-rays for a total payment of $on To date there has not been any payment to [redacted] for any of these services The office sent statements to the insured dated, 122013, and Two messages were left at the insured phone number on fileThe last statement was sent with a sticker stating if there was no response by the insured within days regarding the outstanding balance, the account would go to collectionsThe account was brought to [redacted] ’s attention regarding a lack of payment for any service and the decision was made to put the insured in collections for full fees due to lack of responseThere was approximately months without any response by [redacted] to request for payment on this accountThere is also a lack of response to the collection agency of year in which this complaint was filedAfter year and months neither the collection agency nor [redacted] have received any compensation for the services provided to [redacted]

March **, 2014
RE: [redacted] [redacted]
Complaint#: [redacted]
This letter is written in reply to the complaint made by [redacted] regarding care received by [redacted] was on...

call at Mather Hospital when [redacted] presented with an injury to his left wrist after falling from the monkey bars. [redacted] examined the patient on 10/**/2012 and reviewed all information regarding this injury after which he diagnosed a [redacted]. A bill was sent to the insurance company for the Emergency Room visit ([redacted]) and the [redacted], which is coded as [redacted]. The [redacted] is considered a surgical code because it is part of the Musculosketal section of the Current Procedure Terminology (CPT) coding system.
[redacted] is a non participating provider as [redacted] explained and therefore all payments were sent directly to the policy holder. This is standard policy for Empire New York State Insurance. The patient was sent check#[redacted] for $3010.42 on 11/**/2012 for the Emergency Room visit and the [redacted] care. The patient followed up in our office for follow up x-rays to determine how well the [redacted] and growth plate were healing. [redacted] performed one x-ray per month for 3 months to monitor the healing process. The office billed a total of 3 X-rays in which the insured was issued two checks directly. The first was issued 12/**/12 ck#[redacted] for $68 and the second check was issued for the last two x-rays for a total payment of $132 on 12/**/2012. To date there has not been any payment to [redacted] for any of these services.
The office sent 3 statements to the insured dated, 12/**/2013, 01/**/2013 and 2/**/2013. Two messages were left at the insured phone number on file. The last statement was sent with a sticker stating if there was no response by the insured within 14 days regarding the outstanding balance, the account would go to collections. The account was brought to [redacted]’s attention regarding a lack of payment for any service and the decision was made 03/**/13 to put the insured in collections for full fees due to lack of response. There was approximately 4 months without any response by [redacted] to request for payment on this account. There is also a lack of response to the collection agency of 1 year in which this complaint was filed. After 1 year and 4 months neither the collection agency nor [redacted] have received any compensation for the services provided to [redacted].

Review: On 10/**/12 my son went to the Emergency Room at Mather Hospital in [redacted]., for a [redacted] which had occurred at Bear Mountain State park the evening prior. I have Empire Insurance. I Insisted on an In Plan Doctor. The hospital gave us [redacted] of Orthopedic Associates of Long Island. The doctor said that we was not a participating provider, however the treatment would be covered as your emergency room coverage. [redacted] treatment amounted to a plaster cast on my sons arm. The hospital billed our insurance company for the entire treatment which included 2 sets of x-rays, materials used and the treatment. The insurance company paid more than $3500.00 Unknown to us, Orthopedic Associates of Long Island billed our insurance company a huge amount of money for surgery on the same date. My son did not have any surgery. He simply had a cast put on his arm as part of his emergency room treatment. The insurance company paid [redacted] of Orthopedic Associates of Long Island $3010.40. This additional billing was not known to us until much later.We were sent to Orthopedic Associates of Long Island as follow up treatment to his Emergency room visit. The focus of the Staff and doctors appeared to be how much money they could get from us, rather than the treatment. For example, they wanted more x-rays, but would not take our insurance. They wanted us to pay them about $85.00 per x-ray. Instead, we had the X-rays taken by another lab, [redacted], and hand delivered them to Orthopedic Associates of Long Island at the desk. Even thought we had the x-rays done by another lab, Orthopedic Associates of Long Island billed our insurance company again for the x-rays, as though they had done them. We later found out that Orthopedic Associates of Long Island had also billed our insurance company 3 times, for the x-rays that the hospital actually did on 10/**/2012. Finally, six weeks later, it was time for our son to get his cast off. This was follow up to his Emergency Room treatment. [redacted] said that he would like to get another x-ray, and that they would do it here and not bill us this time, rather than having us go back to [redacted] again. However, this was addition x-ray was billed. We did not hear from Orthopedic Associates of Long Island for about a year. We never received any bill from them, nor any phone calls. Then we started getting computer generated phone calls from a collection agency. They are looking for an additional $12,442.15 for the surgery which is apparently what they calling the cast that [redacted] made in addition to x-rays which they did not do. We contacted our insurance company and Empire told us that the $3010.40 that they paid [redacted] is the Reasonable and Customary amount for the work that he did. We are being grossly overbilled, and they have gone straight to collections without bothering to discuss this with us.Desired Settlement: [redacted] of Orthopedic Associates of Long Island recieved $3010.40, the amount concidered Reasonable and Customary by our insurance company for casting my son's [redacted] at the Mather Hospital Emergency Room. He and Orthopedic Associates of Long Island are attempting to overbill us $12,442.15. We want this overbilling stopped. Thank you for all your help!

Business

Response:

March **, 2014

RE: [redacted]

Complaint#: [redacted]

This letter is written in reply to the complaint made by [redacted] regarding care received by [redacted]. [redacted] was on call at Mather Hospital when [redacted] presented with an injury to his left wrist after falling from the monkey bars. [redacted] examined the patient on 10/**/2012 and reviewed all information regarding this injury after which he diagnosed a [redacted]. A bill was sent to the insurance company for the Emergency Room visit ([redacted]) and the [redacted], which is coded as [redacted]. The [redacted] is considered a surgical code because it is part of the Musculosketal section of the Current Procedure Terminology (CPT) coding system.

[redacted] is a non participating provider as [redacted] explained and therefore all payments were sent directly to the policy holder. This is standard policy for Empire New York State Insurance. The patient was sent check#[redacted] for $3010.42 on 11/**/2012 for the Emergency Room visit and the [redacted] care. The patient followed up in our office for follow up x-rays to determine how well the [redacted] and growth plate were healing. [redacted] performed one x-ray per month for 3 months to monitor the healing process. The office billed a total of 3 X-rays in which the insured was issued two checks directly. The first was issued 12/**/12 ck#[redacted] for $68 and the second check was issued for the last two x-rays for a total payment of $132 on 12/**/2012. To date there has not been any payment to [redacted] for any of these services.

The office sent 3 statements to the insured dated, 12/**/2013, 01/**/2013 and 2/**/2013. Two messages were left at the insured phone number on file. The last statement was sent with a sticker stating if there was no response by the insured within 14 days regarding the outstanding balance, the account would go to collections. The account was brought to [redacted]’s attention regarding a lack of payment for any service and the decision was made 03/**/13 to put the insured in collections for full fees due to lack of response. There was approximately 4 months without any response by [redacted] to request for payment on this account. There is also a lack of response to the collection agency of 1 year in which this complaint was filed. After 1 year and 4 months neither the collection agency nor [redacted] have received any compensation for the services provided to [redacted].