Piedmont Community Health Plan, Inc.

I got insurance through the Healthcare Marketplace with PIEDMONT COMMUNITY HEALTH PLAN (PCHP), and they have been nothing but a nightmare to deal with. They mixed up my individual policy with the policy I had through my employer, which was terminated in 2016. I cannot access my account to see what I’ve paid, what’s going on with it, make a payment, or change my payment method. I have called them. I have emailed them. I have asked to speak with a manager. I have even gone to their office. I warned them that if this did not get resolved, I was going to post on every social media platform exactly what I’ve experienced with them to warn others so they don't have to deal with the overwhelming frustration they’ve put me through. Apparently, they don't care.This has been going on for literally OVER A YEAR! Today I get a message that I owe them over $2,000, and they will not allow me access to my account until I bring them a check. Are you kidding me?! How stupid would I have to be to write them a check when I can’t even access my account to see any kind of proof or documentation?! They’ve screwed up my account, and now they’re going to hold access to my account hostage unless I write them a check when I have no proof that I owe it. What kind of business operates this way? Their behavior shows clear contempt for their policyholders. Save yourself from having to go through this horror show and avoid them at all costs. I wish I had.

I have reviewed the response offer 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.
As far as my complaint with PCHP, yes, I received their response.  My concern is, they have not met what I've asked for at all.  The vendor ([redacted] Health) has taken a loss, but PCHP has still refused to count any of the money that I have paid this year towards this year's deductible.  Being as I'm paying this year, regardless of when the claim was made, it was adjusted this year and asked to pay the remains in this year, so I still respectfully request the money count towards this year.  As they are still not meeting that request, I am unable to accept their response.  They have not even offered a compromise.
[redacted]

This letter is in response to complaint assigned ID [redacted] regarding the member's responsibility for a
hospital bill that occurred in 2012. The member was covered under a group policy with Piedmont
Community HealthCare (a subsidiary of Piedmont Community Health Plan) in 2012.  In the latter part of
2012, she terminated her employment there and went to another company that also had coverage
through Piedmont Community Health Plan.
The member received hospital services in November 2012. The claim was received and processed under
the previous employer on 11/28/2012 since Piedmont had never received a termination of coverage
notice from the previous employer, which should have been effective for 09/30/2012. The member
called Piedmont on 03/01/2013 indicating that the claim was paid under the incorrect plan and we
explained we had not received the termination notice from the group before the claim was processed.
The member stated it was Piedmont's fault and hung up. Piedmont re-processed the claim under the
new group plan on 03/20/2013 and payment was issued. Please note, the member received an
explanation of benefits with each claim that was processed.
Breakdown of claim processed:
PreviousEmployer: Totalcharge    $3,119.61
                               Discount        $1,123.06
                         Member owed       $454.08
                                     Paid         $1,542.47
Current Employer  Total Charge    $3,119.61
                              Discount           $1123,06
                          Member owed      $1,282.51
                               Paid                $714.04
        
The current employer offers two group health plans from which their employees may choose and this
member elected the higher deductible plan offering which also had a higher deductible than the plan
offered by the previous employer.
Since the claim was paid under both group health plans (first one and then the other), the hospital was
carrying a credit on the account. It is also our understanding from the member that she paid $454.08 to
the hospital. Piedmont attempted to request a refund from the hospital on three different occasions for
the first processed amount on the claim ($1,542.47). The hospital finally refunded the payment made
on the previous employer's plan in January 2014. With the difference in group health plans, along with
the higher deductible plan the member had chosen, she was left owing the balance of $828.43.
Piedmont spoke with the hospital billing department after the member called Piedmont on this claim
and they stated they had sent her three billing letters, (02/20/14, 03/22/2014 and 04/21/2014) before
they sent this matter to a collection agency on 05/22/14. Please note, the last billing notice the hospital
sent to the member stated if not paid in full the account would be turned over to a credit agency.
After receipt of your first letter, Ms. [redacted], Manager of Customer Service, contacted the member to
explain what had occurred. The member's complaint is that she wants the amount that she now owes
to the hospital for a corrected claim that occurred in 2012 to apply to her 2014 deductible/out-of-pocket
instead of the 2012 deductible/out-of-pocket amount that was in effect at that time. We attempted to
explain that accumulators are based on the year in which the service was provided and we could not
apply 2012 benefit accumulators to the 2014 benefit year.
Ms. [redacted] contacted the hospital prior to calling the member to see if there was anything they could do
with the bill since the hospital had held a credit on the account for so long. The hospital agreed to write
off 50% of the balance and they would contact the member to advise. Ms. [redacted] explained all of this to
the member and that the hospital would be contacting her. The member expressed she was still not
happy because she wanted us to apply the amount to her 2014 out-of-pocket and she would write a
letter to the Revdex.com every day until she got what she wanted. Ms. [redacted] followed back
up with the hospital to see ¡f they had contacted the member. The hospital confirmed they had and she
accepted the 50% write off and would pay the remaining balance.
The employer's plan that currently covers this member is a self-insured plan in which the employer
funds their own claims and Piedmont administers the plan for them. This issue was discussed with the
employer before Ms. [redacted] called the member back. We explained to the employer what the member
was requesting regarding the accumulators and the employer group was not inclined to apply this
amount to the 2014 accumulators.
I hope this has addressed your concerns. If you have any questions please feel free to contact me at[redacted]
Sincerely,
[redacted]
Director, Operations, Compliance and Security

This letter is in response to the complaint that The Revdex.com received from [redacted],ID [redacted], regarding services/customer service from Piedmont Community Health Plan (Piedmont).
Piedmont reviewed the complaint, notes, and recorded phone calls relative to this member. Due to...

the sensitivity of the information and HIPP A privacy rules, Piedmont cannot provide detailed information to The Revdex.com. However, Piedmont's Customer Service Manager, [redacted], will be contacting Ms. [redacted] to discuss the situation and answer any questions and concerns she has specific to this complaint and the service she received.
Thank you
Sincerely,
[redacted] Director, Operations, Compliance & Security

I have reviewed the response offer 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.
I was contacted by both the vendor, [redacted], and the insurance company, PCHP.  I am dissatisfied with the insurance company, PCHP.  They offered no resolution whatsoever.  They contacted me to notify me that [redacted] did not respond in a timely manner and then PCHP refused to work with or adjust this year's deductible and max out of pocket amount. Due to the fact they are able to make adjustments for their benefit OUTSIDE of the year in which claims were made, they should likewise be able to make the same adjustments for the customer outside of the claim year.  They retracted the amount owed for the claim in January 2014, leaving me with the bill to be paid in 2014, but they refuse to allot the amount paid for this year's deductible or out of pocket maximum.  The purpose of a deductible is to give a reasonable and accountable (planned  for amount) for the customer to pay within twelve calendar months.  To ask me to be prepared to pay the remaining 2012 claim adjusted in January in addition to any additional bills for this year is outside the bounds of reasonable.  Besides the fact, the money is paid in 2014, the money should count for 2014.  
 
PCHP refuses to acknowledge the impossibility of billing for the past in the present while only applying it in the past, therefore effecting the ability to pay other present deductibles and out of pocket expenses.
 
Contact was made with [redacted] who referred me to the director of her dept, [redacted].  
 
Regards,
[redacted]

Review: January 30, 2014, I called PCHP, my insurance provider through my school, for a problem regarding a prescription refill. Before I could even ask my question, I needed to verify all my information: name, date of birth, address, etc. This was fine and acceptable despite the fact that I threw up twice during the call. I then was told that I did not have a policy with them at all, that it had been cancelled as of September 30th, 2013 and they could not help me with any questions. I repeated my information, including the policy card number that had the CURRENT date and information. I was told I did not have an account and would not be assisted.

I was told to contact my school directly, which I did, and they verified my insurance was not only active, but current. They gave me a third party company that is purchased THROUGH my PCHP provider. They acknowledged my current and active policy as well and even offered and called the pharmacy directly to get the prescription filled as quickly as possible.

Not only did PCHP not provide accurate information, they did not give me the information pertinent to the call: the third party company that could have verified my policy.

Additionally, as of May 28 and 30, 2014, further assistance was required. Both calls were handled unprofessionally. The first call, no questions could be answered because the employee had to look over the account. No questions of the policy were answered at all with anything other than, "I'll gather the information and call you back." I feel if the employees cannot answer simple questions about the plethora of account information at their fingertips, they are not a trustworthy or well trained business. The second call was even worse, to the point that at one time, the employee disagreed with me as to whether they handled prescriptions. The dispute was "handled" by the employee hollering to a colleague WHILE I was still on the line about the question and then, when the response was issued, the employee seemed to not understand anything was handled unprofessionally.

I was denied the ability to talk to a supervisor when asked.

I was denied information about how the appeal process is handled, what I could expect as the outcome.

Before that I was informed that all information on discussing such changes were made through a corporate office in [redacted] and that it could not be handled directly by the customer at all. Only when insisting I speak to a person myself, and not depend on the unprofessional and inept ability of the employee was I offered the chance to talk to a supervisor (who declined the call) only to be given completely different information on the appeal process.

When asked who handles the appeal again, I was told the supervisor! The same supervisor that would not even take the call nor address the immediate concerns.Desired Settlement: All of this said, the original complaints that necessitated the phone calls in the first place hinge on the inability of PCHP to handle claims effectively. Due to the proven problem in training, customer service, and accounting, as evidence by my contact with the company over multiple attempts, I am requesting the billing adjustment be honored. The mistake of the company, the lack of professionalism and ill-timed accounting, resulted in a $1282.51 error found in a claim made 2012. IF the money is required to settle, the amount should be either covered by PCHP or allowed in the current billing year, going towards the current out of pocket expense and deductible of 2014 since the payments are expected in 2014. You can't bill for the past in the present and credit it towards the past while not applying it to the present. Paid in the present: applied to the present, regardless of services rendered.

Business

Response:

This letter is in response to the complaint that The Revdex.com received from [redacted],ID [redacted], regarding services/customer service from Piedmont Community Health Plan (Piedmont).

Piedmont reviewed the complaint, notes, and recorded phone calls relative to this member. Due to the sensitivity of the information and HIPP A privacy rules, Piedmont cannot provide detailed information to The Revdex.com. However, Piedmont's Customer Service Manager, [redacted], will be contacting Ms. [redacted] to discuss the situation and answer any questions and concerns she has specific to this complaint and the service she received.

Thank you

Sincerely,

[redacted] Director, Operations, Compliance & Security

Consumer

Response:

I have reviewed the response offer 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.

I was contacted by both the vendor, [redacted], and the insurance company, PCHP. I am dissatisfied with the insurance company, PCHP. They offered no resolution whatsoever. They contacted me to notify me that [redacted] did not respond in a timely manner and then PCHP refused to work with or adjust this year's deductible and max out of pocket amount. Due to the fact they are able to make adjustments for their benefit OUTSIDE of the year in which claims were made, they should likewise be able to make the same adjustments for the customer outside of the claim year. They retracted the amount owed for the claim in January 2014, leaving me with the bill to be paid in 2014, but they refuse to allot the amount paid for this year's deductible or out of pocket maximum. The purpose of a deductible is to give a reasonable and accountable (planned for amount) for the customer to pay within twelve calendar months. To ask me to be prepared to pay the remaining 2012 claim adjusted in January in addition to any additional bills for this year is outside the bounds of reasonable. Besides the fact, the money is paid in 2014, the money should count for 2014.

PCHP refuses to acknowledge the impossibility of billing for the past in the present while only applying it in the past, therefore effecting the ability to pay other present deductibles and out of pocket expenses.

Contact was made with [redacted] who referred me to the director of her dept, [redacted].

Regards,

Business

Response:

This letter is in response to complaint assigned ID [redacted] regarding the member's responsibility for a

hospital bill that occurred in 2012. The member was covered under a group policy with Piedmont

Community HealthCare (a subsidiary of Piedmont Community Health Plan) in 2012. In the latter part of

2012, she terminated her employment there and went to another company that also had coverage

through Piedmont Community Health Plan.

The member received hospital services in November 2012. The claim was received and processed under

the previous employer on 11/28/2012 since Piedmont had never received a termination of coverage

notice from the previous employer, which should have been effective for 09/30/2012. The member

called Piedmont on 03/01/2013 indicating that the claim was paid under the incorrect plan and we

explained we had not received the termination notice from the group before the claim was processed.

The member stated it was Piedmont's fault and hung up. Piedmont re-processed the claim under the

new group plan on 03/20/2013 and payment was issued. Please note, the member received an

explanation of benefits with each claim that was processed.

Breakdown of claim processed:

PreviousEmployer: Totalcharge $3,119.61

Discount $1,123.06

Member owed $454.08

Paid $1,542.47

Current Employer Total Charge $3,119.61

Discount $1123,06

Member owed $1,282.51

Paid $714.04

The current employer offers two group health plans from which their employees may choose and this

member elected the higher deductible plan offering which also had a higher deductible than the plan

offered by the previous employer.

Since the claim was paid under both group health plans (first one and then the other), the hospital was

carrying a credit on the account. It is also our understanding from the member that she paid $454.08 to

the hospital. Piedmont attempted to request a refund from the hospital on three different occasions for

the first processed amount on the claim ($1,542.47). The hospital finally refunded the payment made

on the previous employer's plan in January 2014. With the difference in group health plans, along with

the higher deductible plan the member had chosen, she was left owing the balance of $828.43.

Piedmont spoke with the hospital billing department after the member called Piedmont on this claim

and they stated they had sent her three billing letters, (02/20/14, 03/22/2014 and 04/21/2014) before

they sent this matter to a collection agency on 05/22/14. Please note, the last billing notice the hospital

sent to the member stated if not paid in full the account would be turned over to a credit agency.

After receipt of your first letter, Ms. [redacted], Manager of Customer Service, contacted the member to

explain what had occurred. The member's complaint is that she wants the amount that she now owes

to the hospital for a corrected claim that occurred in 2012 to apply to her 2014 deductible/out-of-pocket

instead of the 2012 deductible/out-of-pocket amount that was in effect at that time. We attempted to

explain that accumulators are based on the year in which the service was provided and we could not

apply 2012 benefit accumulators to the 2014 benefit year.

Ms. [redacted] contacted the hospital prior to calling the member to see if there was anything they could do

with the bill since the hospital had held a credit on the account for so long. The hospital agreed to write

off 50% of the balance and they would contact the member to advise. Ms. [redacted] explained all of this to

the member and that the hospital would be contacting her. The member expressed she was still not

happy because she wanted us to apply the amount to her 2014 out-of-pocket and she would write a

letter to the Revdex.com every day until she got what she wanted. Ms. [redacted] followed back

up with the hospital to see ¡f they had contacted the member. The hospital confirmed they had and she

accepted the 50% write off and would pay the remaining balance.

The employer's plan that currently covers this member is a self-insured plan in which the employer

funds their own claims and Piedmont administers the plan for them. This issue was discussed with the

employer before Ms. [redacted] called the member back. We explained to the employer what the member

was requesting regarding the accumulators and the employer group was not inclined to apply this

amount to the 2014 accumulators.

I hope this has addressed your concerns. If you have any questions please feel free to contact me at[redacted]

Sincerely,

Director, Operations, Compliance and Security

Consumer

Response:

I have reviewed the response offer 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.

As far as my complaint with PCHP, yes, I received their response. My concern is, they have not met what I've asked for at all. The vendor ([redacted] Health) has taken a loss, but PCHP has still refused to count any of the money that I have paid this year towards this year's deductible. Being as I'm paying this year, regardless of when the claim was made, it was adjusted this year and asked to pay the remains in this year, so I still respectfully request the money count towards this year. As they are still not meeting that request, I am unable to accept their response. They have not even offered a compromise.