POMCO Group

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.As of Friday, March 11, Lupe (billing for [redacted] ) ###-###-#### reports that payment has not been received, resulting in us not receiving our $backIn response to Pomco's assertion that providers on the directories doesn't automatically mean they are covered, I DID call Pomco to verify that [redacted] Radiology (what's listed on our preferred provider list) was actually coveredI explained that they were answering the phone under [redacted] Radiology and I was told [redacted] moved up to Santa Barbara but they were still taking [redacted] patientsI explained all that to Pomco rep PRIOR to my husband's MRI and they gave me info over the phone as wellUntil [redacted] Radiology actually receives payment and we receive our refund, this matter is not resolvedObviously, from past experience with Pomco, trusting what they say: that they sent payment etc does not hold alot of weight Regards, [redacted]

POMCO has now received the bill from the radiology group and it has been paid at 100% of the allowable chargesBoth the member and the provider have been contacted regarding sameThe provider was advised to return the $deductible back to the member as the claim has been directly paid by the
health plan to the provider. The confusion the member mentioned with *** Radiology came from information received from the network that is utilized by POMCO in CaliforniaPOMCO has sent the updated information to the network so they can update their directories and information. Although there is a disclaimer that the member must always check with the providers directly to ascertain whether they are in network prior to any services being rendered as providers enter and leave a network on a daily basis, POMCO appreciates the feedback regarding providers that have left the networkWe are passing on the information.In summary, the $has been paid to the provider who should be returning the $deductible to the memberBoth the member and provider have been contacted by POMCOPlease let me know if you have any questionsThank you

We are in receipt of the complaint filed by the SU member and thank you for sameBy way of background., the members health plan coverage with SU was effective on 8/24/2015. POMCO, a third party administrator for the SU health plan, received the enrollment information from SU on 9/14/
When POMCO receives this information from the client, it is entered into the system to set up the members account and generate ID cardsHowever, the member's coverage was in effect and fully active as of 8/24/2015. On 10/26/2015, POMCO received a call from SU that the member had not received their ID cards yet. A review of the system was undertaken and it revealed that the members account was properly set up and active but, during the enrollment load on 9/14/2015, the members ID card was not issued as the member indicatedA review of the data and systems revealed that the computer did not pick up this members information as a "new" member which is what triggers the production of the ID cardAn ID card was manually prepared and sent overnight mail to the member on 11/6/2015. At no time, however, was the members health coverage in jeopardy. As you may be aware, many times patients go to their providers office without their ID card (the main reason is they forget to bring their card) and the course of business is the provider contacts the health insurance company for verification of coverage prior to treatmentPOMCO receives many calls, daily, from providers seeking ID card information. Accordingly, since the member had fully and active coverage, there would be no reason not to seek medical treatment if needed as the providers would have contacted POMCO for the informationThat being said, I can certainly understand the frustration of not having the ID card and the security it provides.A review of the phone calls that are recorded for quality assurance reasons at POMCO between the Customer Service Representative (CSR) and the member reveal that the POMCO CSR apologized to the member for the automation error a number of timesThe member was, of course, upset that there was a glitch in the system and did not receive the ID card. By way of this response, POMCO, again, apologizes to the member for the delay in receipt of their ID card. If you have any questions, please do not hesitate to contact meKathleen L***, EsqGeneral Counsel and Vice President, Compliance

The claim for this member was finalized on 3/7/16, the day that POMCO responded to the Revdex.com complaint. Once a claim is finalized, it is then sent for payment, entry and check distributionThe claims adjuster called both the provider and member to advise that the claim had finalized and informed the provider that they could expect payment from Anthem, the physician network that is the contracted entity with the provider and that POMCO utilizes in CaliforniaThe POMCO records are clear that both parties were contacted that the claim had been finalized and the provider stated that as soon as they received the payment, they would issue the member her reimbursement for the $deductibleThe member was informed by the claims adjuster of the provider's response.The information that *** Imaging was still taking *** patients was unknown to POMCO until relayed to the Customer Service Representative (CSR) by the memberThe CSR refers to the directory of providers which listed *** Radiology as the radiology service in that areaAs indicated, POMCO has contacted the necessary individuals at Anthem to make sure that the directory of providers is updated with regard to *** RadiologyBecause a provider directory is not static, with providers joining and leaving the network on a daily basis, all insurance companies and health plans have a disclaimer in their directories that a member must always check with the provider (not just the health plan or insurance company) prior to services being rendered to make sure the provider is still participating. It is not uncommon for a provider to leave a network the same day, or close to the day, that services are rendered and the directories would not reflect that new informationThus, the reason that all directories in all insurance companies and health plans state the same thing - it is imperative the member check with the provider to make sure he/she is still in network.POMCO apologizes for the frustration that this member experiencedWe have requested the payment to go to the facility so that they can reimburse the memberWe have also contacted the network to update the directoryAgain, our sincere apologies are extended to the member

Thank you for the additional inquiry.While we are not aware of the exact reason the complainant incurred a late fee at the provider’s office, he states that he could not pay the provider because his debit card had been suspended. The IRS requires debit card purchases to be properly substantiated. When the complainant did not provide the required itemized receipts for his debit card purchases, the debit card was suspendedThe complainant’s account was not suspended, however, only the privilege of using the debit card, in accordance with IRS guidelines. The debit card program is only one of the payment options under the reimbursement plan. The complainant can always pay for medical expenses through other means, such as by using a credit card, and then submit a claim for reimbursement from the plan. This process is explained in the complainant’s plan documentPOMCO is not responsible for late feesThe complainant could have called the customer service number if he was having difficulty accessing his account online to complete the substantiation process in the required timeframe.After thorough investigation, and as stated in our prior response, POMCO receives thousands of electronic receipts from members and providers to be substantiated, on a daily basis, and during the period in question, there were no reported problems with the POMCO systems.After experiencing issues with his electronic account, the complainant could have called customer service to make sure he received the information provided by emailIf the complainant does not wish to receive electronic correspondences, he may opt out by logging into his account and selecting paper mailings only. Alternatively, POMCO could do this on his behalf, if he requests that.POMCO abides by the IRS regulations with regard to substantiation. Once the complainant provided the requested documentation, his debit card was reactivated. At all times, POMCO followed the appropriate process set forth by the IRS regulations with regard to substantiation

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.To  POMCO   Revdex.com   The few thing POMCO did not go into to the Revdex.com was 1 I asked why I should have to pay for the late fees because they suspended my HRA account and could not pay my doctors’ bills at the time of service And did not give me proper notice they need more documentation Their response was SORRY WE DON’T PAY LATE FEES!! That when I got mad very mad 2 there web site was not working I cannot open the link 3 there suspension notification process They send a e mail that tells me go to a web site then to open a link that cannot be open Most computer class tell you not to open links or email with attachment Why it a fast way to fill your computer virus or hackers 4 had they given me proper notifications this matter could have been avoided POSTAL SERVICE LETTER OR A PHONE CALL NOT AN E MAIL DIRECTING ME TO GO TO A WEB SITE THE OPEN A LINK THAT COULD NOT BE OPEN  I work construction in my line of work  You can lose your job over using a phone on the job  From the union hall [redacted] they sent a memo out in 2004 Stating you can’t have a personal phone on the job So I had to leave the site to use the phone to clean up the mess POMCO made 6 as for language I talk to them way I get talked to when I made a mistake They made this mess they need to own up to and clean it up So what they recorded me dropping a f bomb on the phone You should have heard the words and attitude of my supervisor had towards me when I told him I was on the phone on hold with the POMCO on his time I AM PAYING TO BE ON HOLD IETHER GET TO WORK OR I CAN SIGN THE BOOK then his verbal abuse vulgar language POMCO breaking the law telling me I am stuck with the late fees because of them not going thou the proper notification when they made the mistake not me Typical insurance co look for reason not to pay or delay payment  Regards,  [redacted]

Thank you for the information detailed in the complaint. As you are probably aware, debit card substantiation is the process of verifying that purchases made using a debit card are for an eligible medical expense as per IRS guidelines.  POMCO strictly follows those guidelines and, as...

such, must substantiate the purchases made by debit card for HRA, HSA's and flex plans.  In this matter, the complainant was upset that POMCO had to substantiate his debit card swipes. He stated that he did not need to do that in the past.  A review of his files indicates that his prior purchases were, indeed, substantiated which, of course, is a requirement of the IRS. However, his provider, Empire Vision Works, sent the substantiation documents directly to POMCO thus eliminating the need for the member to get involved. In this situation, the receipts were not sent directly to POMCO by the provider and, thus, POMCO needed to obtain them directly from the member. These requirements of the member are clearly set forth in his plan documents.  A review of the recorded phone calls indicate that the member tried to submit the receipts over the internet but he was having difficulty with the electronic submission. In the recorded phone calls by the member to POMCO, the member repeatedly used disturbing and profane language towards the Customer Service Representative (CSR) for making him substantiate the receipts when he did not need to do that in the past and alleged that our system was broken so that he could not submit the receipts. Please be advised that POMCO receives thousands of electronic receipts from members and providers to be substantiated, on a daily basis, and at no point in time has there been a problem with the POMCO systems receiving such receipts.  During the time in question, the POMCO systems were functioning properly and there were no scheduled upgrades performed at that time that would have affected the system.  Moreover, receipts continued to be received at POMCO from other members and providers on the system during the same time. Typically, when there are issues with the electronic submission of receipts, the problem lies on the user end and some of the restrictions they may have on their computers.  It is unfortunate that this member was frustrated by the process for debit card substantiation but the process POMCO followed is not something that POMCO created - it is a mandated process set forth by the Internal Revenue Service.  Of course, having one's debit card denied is not a pleasant experience and we apologize for the inconvenience that may have caused the member. However, at all times, POMCO followed the appropriate process set forth by the IRS regulations with regard to substantiation.

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.As of Friday, March 11, Lupe (billing for [redacted]) ###-###-#### reports that payment has not been received, resulting in us not receiving our $300 back. In response to Pomco's assertion that providers on the directories doesn't automatically mean they are covered, I DID call Pomco to verify that [redacted] Radiology (what's listed on our preferred provider list) was actually covered. I explained that they were answering the phone under [redacted] Radiology and I was told [redacted] moved up to Santa Barbara but they were still taking [redacted] patients. I explained all that to Pomco rep PRIOR to my husband's MRI and they gave me false info over the phone as well. Until [redacted] Radiology actually receives payment and we receive our refund, this matter is not resolved. Obviously, from past experience with Pomco, trusting what they say: that they sent payment etc does not hold alot of weight. 
Regards,
[redacted]