Portland Wellness Center

Dear Ms. [redacted]:
Thank you for forwarding customer complaint [redacted] to me.
Before our appointment, the customer completed a questionnaire that asked for her insuranceinformation. The insurance company and network the customer provided in her questionnaire wasMODA, Con nexus Network.At the time...

of her 09/24/2015 office visit I was credentialed with the insurer and network the patientprovided. At some point between 9/16/2015, when the customer's insurance information was firstaccessed from her questionnaire, and prior to her 9/24/2015 office visit, staff here contacted thecustomer's insurance company, MODA to get her benefit information. The notes from the call indicateMODA provided us information on her in-network benefits. She had met her individual deductible of$2500 and her out-of-pocket maximum of $6000. Our notes also indicate the service we intended toprovide was a covered service for the customer. The policy number on our notes matches the policynumber the patient provided. Based on the information we had, we were confident the customer'sappointment would be covered by her insurer as in-network. Unfortunately, health insurers do notprovide guarantees of coverage when providing benefit information, which is the reason we always askpatients to sign an agreement that they will be responsible for charges their insurer does not pay. Thecustomer did sign the agreement.
After the customer's office visit, we were surprised and disappointed that her insurance denied theclaim on 10/28/2015, stating she Is not in the Con nexus Network, making my services out-of-network.Further, she had not met her out-of-network deductible, which caused her to be responsible for thecharges. Upon review of a copy we made of her insurance card that was presented at the time of thevisit, we noted a different network was identified on her insurance card (Community Care Network).On 11/04/2015 staff here sent a bill to the customer for $270 ($300 minus the $30 co-pay she providedat the time of her visit). The customer emailed us asking if the bill was in error. We informed it was notan error. We reiterated that that based on the information we had prior to her visit, we expected theservice to be covered by her insurer. We were surprised it was not. I offered to help the customerappeal the denial from her insurer. Her response was, "Feel free to explore an appeal if that will get youpaid, but please note my issue is not with MODA but with your office". I appealed the denial on the customer's behalf to MODA on 11/19/2015. Unfortunately, the appeal was unsuccessful. In the denialof her appeal, MODA acknowledged that they informed us during the call that, "After the out-of-pocketmaximum has been met, the Plan will pay 100% of covered services for the remainder of the year".
MODA also states the amount charged for the service, $300, was allowable and has been applied to thecustomer's deductible. We sent the patient a 2"' bill dated 12/10/15. On December lS'h we received awritten response from the customer stating, "I have no intention to pay this invoice ... and am willing torisk my otherwise exemplary credit rating". We sent the 3'd bill dated 02/02/2016 and asked thecustomer to pay by March 7 if she wishes to avoid having the bill turned over to collections.
Since we did not confirm that the insurance network information provided by the customer was thesame as the information on her insurance card, I am willing to reduce the amount of her charge by 50%.She paid a $30 co-pay at the time of her visit, so the remaining charge is $120. Further, I have not sentthis matter to collections and do not plan to at this time.
Regarding the issue of the $700 lab fees: I did not hear about this issue until the customer's complaintand the $700 fee is not being generated by our office. I did order lab tests that are the standard of carefor people with the customer's circumstances. Please know I am also frustrated when insurers do notcover care that is the recognized standard.
Thank you for your assistance in this matter. Please let me know if you need more information from me.Sincerely,Nancy L[redacted]
Nancy L[redacted], RN, CNS, APNG, AOCNS, LLC