Presbyterian Healthcare Services

Dear Revdex.com,We have responded directly to the patient in writing and verbally regarding this issueUnfortunately due to HIPAA privacy rules I am unable to disclose any additional information Sincerely, Jana M [redacted] , CoordinatorPatient Relations Support ServicesPhone: *** [redacted] -Fax: [redacted]

[A default letter is provided here which indicates your acceptance of the business's response If you wish, you may update it before sending it.] Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me Regards, [redacted] ***

The issue has been resolvedThis was communicated to the patient verbally and he will receive a response in writing as wellDue to HIPAA guidelines we are unable to provide any information about the outcome of our reviewThank youJana M [redacted] , CoordinatorPresbyterian Patient Relations Support ServicesP [redacted]

Dear Sir/Madam, Attached is the signed HIPAA release form you requested regarding complaint ID [redacted] I also sent a fax with this information for your convenienceThank You, [redacted] -

December 22, 2015Mr [redacted] ,Presbyterian Health Plan is in receipt of the complaint that you filed with the Revdex.com comlaint # [redacted] According to our records, you have filed previous complaints and appeals with Presbyterian Health Plan regarding this matter pertaining to the classification of continous glucose monitor sensors Your previous grievances and appeals have been addressed in May 2015, June and currently we have a new appeal that we received on December 18, for dispute with claim cost-share and classification for services provided by [redacted] on 11/30/15.Presbyterian Health Plan has responded to your appeals and grievances previously and currently is reviewing the appeal filed on 12/18/ You will be receiving a written response to your appeal on or before January 5, regarding this new recent Administrative Grievance (appeal) filed.Thank you,Geri AM***Regulatory Appeals & Grievance CoordinatorPresbyterian Health PLan

Complaint: [redacted] I am rejecting this response because: 1) AN AUTOMATIC CROSSOVER TO MEDICARE FOR MY PART B, SUPPLEMENTAL INSURANCE BILLING HAS NOT BEEN RESPONDED TO , IN THEIR BUSINESS RESPONSE AND 2) The Presbyterian Care Team Coordinator has created a catastrophic mistake (BY SWITCHING MY CURRENT ENROLLMENT IN ORIGINAL MEDICARE (FOR PARTS A &B ONLY) TO THEIR DATABASE FOR MEDICARE ADVANTAGE MEMBERS, WHICH IS TOTALLY INCORRECT.I mailed a handwritten, more detailed response to your office on Friday, March 25, 2015, since my home computer was not operational at that timeIt is now operational.Regards, [redacted] [To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason the complaint will be closed Answered]

Hello,We are in receipt of this grievance and will reach out to the patient todayOn 8/17/we will provide a brief outcome of our resolution to the Revdex.com and the patient.Sincerely,Jana M [redacted] , CoordinatorPresbyterian Delivery Systems Complaint Services [redacted] *** [redacted]

June 17, RE: Complaint # [redacted] Dear Revdex.com: Presbyterian Healthcare Services received complaint # [redacted] and have reviewed and responded to Ms [redacted] complaint Please find attached complaint closure letter sent to Ms [redacted] on 06/10/ In addition, the Presbyterian Healthcare Services EWCM Coordinator advised that normally, charges are not discussed with patients during their visit as the staff does not know the full extent of the chargesMs [redacted] received the appropriate services and the labs were necessary to diagnose her conditionThe charges were reviewed to determine accuracy and the charges are correctWe apologized that she felt the charges were high and usually we review our charges annually which are competitive within the marketBased on our review, we are unable to adjust the charges as they were billed appropriately The EWCM Presbyterian Healthcare Services EWCM Coordinator suggested that Ms [redacted] appeal with her insurance carrier Blue Cross Blue Shield (BCBS) or inquire on why her insurance left her with such a high balanceIn addition, Ms [redacted] was also referred to the Presbyterian Healthcare Services Patient Financial Services Department to sa payment plan at ###-###-#### Thank you, Geri AM [redacted] Regulatory Coordinator Presbyterian Health Plan/Healthcare Services

In response to Ms [redacted] ***'s concerns, we have contacted the Care Team Coordinator with Presbyterian Health Plan Claims Coordination of Benefits department for review The Care Team Coordinator advises that her Part B Supplemental Insurance or Crossover to Medicare billing in Presbyterian’s database has been updated to reflect the date of 06/01/It is my understanding; it is the member’s responsibility to advise Medicare of this changeMs [redacted] can reach Medicare Coordination of Benefits at ###-###-####, to give them this updated informationThis information has also be entered into the Electronic Correspondence Referral System (ECRS), which is a database used for Medicare contractors to exchange information with Medicare Advantage members Additionally, we have contacted a Specialist with Presbyterian Health Plan Claims Care Unit regarding her request to have an audit of your claims from June to presentAfter completion of the audit; we have determined that an Explanation of Benefits (EOB) is necessary for the following claimsThe EOB's have been requested, and once this information is received we will submit the EOB's to the Claims Care Unit for re-processing of these claims: Date of service: Claim #: [redacted] Claim #: [redacted] Date of service: Claim #: [redacted] Date of service: Claim #: [redacted] Date of service: Claim #: [redacted]

Complaint: [redacted] I am rejecting this response because: Firstly, although MsM [redacted] states that they do not have "the automatic cross system" I have requested, that does not mean that they can set one up as I have request As a matter of fact, Medicare agents have recommended it to me, when they notified me that their claims database shows no record of my Part B, Supplemental Insurance The procedures for setting it up is included in Medicare.gov website; there's a sections on "crossovers." Secondly, I have repeatedly been told by MsStacey S [redacted] (both in a letter she mailed to me, and when I spoke to her by phone, recently) that they have switched my Part B enrollment FROM: Presbyterian Federal Health Plan, Enrollment: High Option, Self Only, Enrollment Code P21, TO: an Advantage Plan First and foremost, that is unlawful, because no one has the authority to change my medical insurance coverage but me I have repeatedly asked in my previous Revdex.com response by mail and in my last phone conversation with MsS [redacted] that such action is not accurate and should be immediately taken out of that system MsM [redacted] 's response does not even mention this very serious situation Until, I receive official notification, through this Revdex.com response system, that they have corrected this most serious situation they have created I will not accept business response Thirdly, MsM***'s business response also failed to even mention my original and still active request to conduct an audit of all Presbyterian bills I have paid from June 1, until the present MsS [redacted] identified which claims were being reviewed in her letter she mailed to me recently I have retained her letter in my personal, complaint file Final response I do not accept business response Regards, [redacted] [To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason the complaint will be closed Answered]

June 30, 2016RE: Complaint # ***Dear Revdex.com:In regards to the rejection submitted by the customer Ms*** *** we have further reviewed the concerns expressedBased on the clinical concerns Ms*** has brought to our attention regarding the high out of pocket expenses incurred for the influenza testing, we have forwarded all our research to the Presbyterian Healthcare Services Primary Care Medical DirectorThe Presbyterian Medical Director will review all the research, Ms*** medical chart to determine if the labs were appropriate to diagnose and treat the patient's medical conditionPlease allow an extension of at least (7) days to further review the matter and provide a response to the customers concernsThank you,Geri AM***Presbyterian’s Regulatory CoordinatorEnterprise Wide Complaint Management

Complaint: ***
I am rejecting this response because the latest response stated that it will take days to gather findings directly from the doctor. If I don't reject this, this will be closed in business days. I appreciate that Presbyterian is forwarding to the medical director. Thank you
Regards,
*** *** [To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason the complaint will be closed Answered]

Complaint: ***
I am rejecting this response due to the following:
First I
would like to note that Presbyterian’s Revdex.com response seems to be an almost
identical letter as I originally received when dealing with them in my pre-Revdex.com
original complaint. I feel Presbyterian
is failing to address my original complaint that I was never told that one lab test for a public health
issue (influenza) would cost me almost $1000.
This price was outrageous for simple confirmation of what I had already
been prescribed flu medicine (Tamiflu) for by the prescribing physician. Furthermore, Presbyterian thinks (as stated
in their response) that the $lab test to confirm the flu strain is “competitive”. I absolutely disagree. Most people I have told about this or spoken
to in Presbyterian billing have agreed that this is an insane amount of money
to diagnose what I had already been prescribed medication for. This practice of coercing the patient into
unexpected costs is deceptive, costly and financially burdensome to the
patient, and violates the trust between the patient and Presbyterian. The prescribing
doctor had already prescribed Tamiflu medication to treat what he and I both
knew was likely the flu. I personally
didn’t care what strain of flu I had but blindly followed the doctor’s orders,
not knowing the consequenceI simply
feel I should have been notified that the additional lab test would cost me
$881. Based on the outrageous price of
this one lab test, I would have appreciated the ability to decide whether it
was financially worthwhile for me to undergo the test. Knowing what I know now, I would never have
chosen to undergo this test.
Regards,
*** *** [To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason the complaint will be closed Answered]

Complaint: ***
I am rejecting this response because: I DID NOT ORDER, PAY OR RECEIVE AN INFUSION PUMP(S) FROM *** ***
After reading your response, I feel both morally and
intellectually discouraged. When an
organization is careless about facts, or plays fast and loose with logic, it is
often because they are trying to make it seem (to themselves as well as others)
as though the ideas to which they are strongly committed can be made to fit
together. Identifying incorrect facts
not only clarifies the issue but helps sharpen the disagreement and also offers
important indications of what the real motivations are
My motivation is to remain healthy
Liz M***, EWCM Research Specialist, in her most recent
correspondence wrote, “The contractual amount billed for the external infusion
pump was $556.00…” I did not order,
receive or pay for an external infusion pump(s) from *** ***
Corporation on or around 11/30/2015. The
price for an external infusion pump is approximately $6000.00. I did purchase four(4) boxes of MMT-
Quick-set 9mm Cannula / 43" Tubing (10/box) for single use in a ***
infusion pumpI also purchased two(2)
boxes of MMT-7008A Enlite Sensors (5/box) for single use in a ***
transmitterThese are single use items like glucose test strips. Glucose monitoring test strips are considered
a pharmacy benefit with the Presbyterian Health Plan. A previous appeal was denied because “…the
sensors are considered DME because this equipment is designed for repeated
use…” This is factually incorrect.
Insurance plans including ***, ***, *** and
*** have considered CGM sensors as a pharmacy benefit, as well as some
union and smaller plans in and around the regional US.
I have provided clinical studies and the websites of each
Continuous Glucose Monitoring(CGMs) sensor manufacturer so you may better
understand what has been categorically denied
Continuous
Glucose Monitoring and Intensive Treatment of Type Diabetes
The *** *** *** *** Continuous Glucose Monitoring Study Group * *** * *** *** ***
A
Comparative Effectiveness Analysis of Three Continuous Glucose Monitors
*** ** ** * *** *** *** *** *** *** ** ** *** ***
Glycaemic control in type diabetes during real time
continuous glucose monitoring compared with self monitoring of blood glucose
*** ** *** *** *** ***
Effect of
Continuous Glucose Monitoring on Hypoglycemia in Type Diabetes
*** ** ** *** *** *** *** ***
Sustained
Benefit of Continuous Glucose Monitoring on A1C, Glucose Profiles, and
Hypoglycemia in Adults With Type Diabetes
The *** *** *** *** Continuous Glucose Monitoring Study Group
Diabetes Care***
The use
and efficacy of continuous glucose monitoring in type diabetes treated with
insulin pump therapy: a randomised controlled trial
*** ** ** *** *** *** ***
Short- and Long-Term Effects of Real-Time
Continuous Glucose Monitoring in Patients With Type Diabetes
*** ** ** *** *** *** *** *** ** *** * ***
Effect of
Continuous Glucose Monitoring on Hypoglycemia in Type Diabetes
*** ** ** *** *** *** *** ***
Accuracy
of two continuous glucose monitoring systems: a head-to-head comparison under
clinical research centre and daily life conditions
*** ** ** *** *** *** *** *** *** *** ***
Perceived
Accuracy in Continuous Glucose Monitoring: Understanding the Impact on
Patients
*** ***Journal of Diabetes Science and Technology published online Nov
A
Clinical Trial of the Accuracy and Treatment Experience of the *** GSensor
(*** GSystem) and Enlite Sensor (Guardian REAL-Time System) Tested
Simultaneously in Ambulatory Patients with Type Diabetes
*** ** *** Diabetes Technology and Therapeutics *** ***
Real-Time
Continuous Glucose Monitoring Significantly Reduces Severe Hypoglycemia in
Hypoglycemia-Unaware Patients With Type Diabetes
*** ** *** Diabetes Care 2013; ***
***
***
Since Presbyterian Research Specialists are unable to
decipher information in the 15-day policy window, it is unreasonable to think
that any member (including myself) can provide sufficient information in
one-hour to a committee (which may consist of EWCM Research Specialists) making
important health benefit decisions. Due
to the fact that Presbyterian was unwilling to accommodate any additional time
for testimony and cancelled my Level II reconsideration hearing, I requested
the filing and processing of an adverse determination on 09/22/2015. This was confirmed via email with Charmain
R*** on 09/23/2015. Your company has yet
to provide a response
On 12/18/at 1:36pm, I made contact with the *** ** *** employee benefit management department regarding this benefit. It was stated that they have no authority to
add or remove products from the Presbyterian Health Plan formulary
Upon also speaking with *** representatives concerning
Continuous Glucose Monitoring Sensors(CGMs) and their sales as a pharmacy
benefit, I was told the issue is not for a patient or manufacturer, but for the
(private) insurance company to make that possible
*** Continuous Glucose Monitoring Systems are now covered
as a Pharmacy Benefit and included on the National Covered Formularies of the
largest Pharmacy Benefit Management companies in the country.
Please reverse your denial, and return to Presbyterian’s
purpose, to improve the health of individuals, families and communities
Respectfully,
*** ***-
[To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason if he complaint will be closed Administratively Resolved]

June 2, 2016 Presbyterian Health Plan is in receipt of complaint # *** received on 05/23/for Ms*** *** for (*** ***). We are currently reviewing this appeal case under the New Mexico Superintendent's regulatory requirements as a "Administrative Grievance
Review". As a health plan we must follow the regulatory times frames set forth by the Superintendent's Office for cases such as these and this file is due for closure on or before June 14, 2016. Once the case is completely reviewed we will copy your office on the response that is being set to the Presbyterian Health Plan member Ms*** R***.Any questions please let me know.Thank you,Geri *M***Enterprise Wide Complaint Management

Complaint: ***I am rejecting this response because:
I am unable to recoup, recover, or regain monies lost. The same individual who based their denial on incorrect information, EWCM Research Specialist, Liz M*** is again handling this issue based on the most current correspondence from Presbyterian Health Care
Unfortunately, any question or concern that cannot be answered by the Presbyterian Health Care customer service staff, must be addressed by a member/(me) filing an “administrative grievance.” It is my understanding that it is against Presbyterian Health Care policy to allow any members/(including myself) to speak with representatives of the Presbyterian Pharmacy Department. Therefore, a member’s question or concern pertaining to a pharmaceutical or pharmaceutical benefit, must again, be addressed by filing an “administrative grievance.”
I have followed the procedure set forth by your organization and regulatory agencies to have simple questions addressed. For example, “Why does Presbyterian consider continuous glucose monitoring sensors durable medical equipment (DME) when compared to glucose monitoring test strips which are considered a pharmacy benefit?”
On July 21, I received a response from your EWCM Research Specialist, Liz M*** which is/was factually inaccurate. My “administrative grievance” was denied. EWCM Research Specialist Liz M*** wrote, “Basically, the sensors are considered DME because this equipment is designed for repeated use as to where test strips are considered pharmacy because they are not designed for repeated use.” Continuous glucose monitoring sensors like glucose monitoring test strips are used ONLY once.
Based on the byzantine procedures set forth by your organization, I requested an “Administrative Grievance Reconsideration Committee Hearing” on August 10, 2015. Having enlisted diabetes health care professionals and company representatives, I requested appropriate time to provide expert testimony to the Reconsideration Committee panel. My request was denied on August 27, because Presbyterian policy only allows for a 1-hour hearing. On September 17, my “Level II Appeal/Administrative Grievance Reconsideration Committee Hearing Request” was cancelled effective that date
On December 18, I have again asked a simple question. Why am I paying more when using my insurance plan directly?
Respectfully,
*** ***-
[To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason if he complaint will be closed Administratively Resolved]

July 13, 2016 RE: Complaint # *** Dear Revdex.com, This is a follow up regarding complaint # *** pertaining to a billing matter for services received on March 8, at Presbyterian Medical Group StMichaels Family PracticeThe concerns we received stated that the patient is upset with the high cost for laboratory services the provider ordered The patient stated that the physician and the nurse should have advised her prior to receiving services how much they would cost before they were ordered. According to our records, the provider was looking for possible influenzaThe patient received appropriate services and the labs were necessary to assist the provider to determine the diagnosis and treatment planIt is an expectation that providers explain the medical necessity for the labs and we apologize if this was not done during her visitNormally, charges are not discussed with patients during their visit as the staff does not know the full extent of the charges and will only provide services based on the patients complaintsThe charges were reviewed to determine accuracy and the charges are correctIt is also an expectation that our patients are fully aware of their own benefits as we are only a service provider and may not know the full extent of their insurance benefits However, after reviewing this matter further, the Presbyterian Healthcare Services Medical Director and Vice President of Presbyterian Medical Group reviewed all our research and the patient’s chart and agreed to adjust the charges for the labs onlyWe will educate the provider for these types of issues going forwardWe strongly believe that communication is an integral part of providing quality health care and appreciate this feedback so that we may continue to improve our care and services. Additionally, on July 6, 2016, a call was made to the patient Ms*** and advised her that the charges for the labs have been adjustedThe concerns she brought to your attention have been resolved Thank you, Geri AM***, Regulatory CoordinatorEnterprise Wide Complaint Management DepartmentPresbyterian Healthcare Services/Presbyterian Health Plan

Mr***,In order for Presbyterian Health Plan to review a health plan member's dispute regarding charges/cost-share it must go through the proper regulatory process per regulations we must follow per the New Mexico Superintendent of Insurance Offices specifically pertaining to monetary issues. According to your complaint, you are disputing your cost-share for services provided by *** *** *** on date of service 11/30/and feel that you would pay less not utilizing your insurance and feel the classification of these services should be categorized differently. Therefore, based on this dispute and regulations we must follow, your concerns were addressed by the Presbyterian Health Plan's Appeals & Grievance Department. MsLiz M***, EWCM Appeals Research Specialist has reviewed your current Administrative Grievance (Level I Appeal) and has upheld the cost-share applied for these services on 11/30/15. The Level I Administrative Grievance uphold appeal decision letter (attached) was sent and mailed to you today 01/05/explaining the uphold decision. Please know that you do have the right to continue on with the appeal process and request a Level II Administrative Grievance Reconsideration Committee Appeal Panel Review. The form is attached to the letter to request this hearing. These Level II Appeal Hearings are conducted in (1) hour increments in order to accommodate members requesting Level II Appeal Hearings. In regards to your inquiry pertaining to the classification of glucose monitor sensors and external infusions pumps, I've contacted the Presbyterian Health Plan's Marketing Representative that works directly with the group (*** ** ***) in which you are insured with and they have advised that you may contact your Benefit Administrator with the *** ** *** regarding your benefits and servicesThis is a benefit purchased by your employer and we are following the benefit plan structure appropriately and processing your claims in accordance with the plan.Thank you,Geri AM***Regulatory CoordinatorPresbyterian Health Plan

HIPAA as requested. Thank you

April 19, 2016Dear Revdex.com:Complaint # ***The response below is regards to Ms*** ***'s rejection to Presbyterian Health Plan's previous response(s):Ms*** ***'s concerns have been reviewed by the following departments at Presbyterian Health Plan and have provided the response below:Presbyterian's Health Plan's Sales/Marketing, Claims, Medicare Enrollment, Coordination of Benefits, Education/Out Reach, Information Technology (IT) and Senior Marketing Account Executive Medicare Sales Department(s).After review of all systems we have determined that we do
not have the “automatic crossover system” that Ms***'s seeksPresbyterian feels what is
occurring is that charges are usually transferred over from Medicare to Presbyterian
Health Plan (PHP) on her behalf; and PHP may also submit charges on this end
as well, but primarily they are transferred over from Medicare. However, there is a Presbyterian system time delay
related to processing Medicare as primary and therefore leaving patient responsibility;
whereas this would normally be captured on a report for the billing team to
reverse the patient responsibilityAnother Presbyterian system is triggered
when the explanation of benefits (EOB) generates a bill for the member because of the
balance due showing on the account, however not all accounts are caught before
a statement is generated and this is why sometimes a bill is received. Management has been notified of this issue
and the Business Office makes every effort to catch these errors before they go
out; unfortunately, this does not always happen resulting in patients receiving
billsPatient Financial Services (PFS) has been instructed to transfer calls
such as yours to the Business Office immediately to have the balances adjusted
Because Ms***'s Medicare plan is primary to her Federal Retiree plan, providers
submit to Medicare first, then submits the claim with the Medicare EOB to Presbyterian
Health Plan for processing. Based on review of some of the claims, they all have had Coordination of Benefits (COB)
applied appropriatelyAgain this is a known issue within PFS and the Business
Office and process changes are being implemented to correct this. On behalf of Presbyterian Health Plan, we
sincerely apologize for your concerns and any inconvenience that this may have
caused youSincerely,Geri AM***, Regulatory CoordinatorEnterprise Wide Complaint ManagementPresbyterian Health Plan