ProHealth Care, Inc.

Please reach out to the Emergency Department manager at 262-928-2477 so we can discuss further.

Review: I had a wellness visit on November 28, 2012 with [redacted] of ProHealth Care Medical Associates in Sussex Wisconsin. It was made clear to the scheduler of the appointment and the physician at the beginning of the appointment that the purpose of the visit was preventive health only. I refused a Pap smear because I was not due for one and the physician changed the nature of the visit to an office appointment noting in my chart that I refused a physical exam. I was not offered a physical exam, I was offered a Pap smear, and it was both appropriate and my right to refuse a Pap smear. Because this appointment was changed to an office visit, my insurance did not pick up any of the charge. I have made repeated attempts both by phone and in writing to ProHealth Care to have this corrected without success.Desired Settlement: This matter could be resolved if the appropriate type of visit (ie. preventive care) be assigned so that my insurance cover the appropriate portion as is in my policy. I will then pay any remaining fees.

Business

Response:

I am the Risk Management Officer for ProHealth

Care, which would include Oconomowoc Memorial Hospital. I received the

letter regarding Georganne [redacted], matter ID #[redacted]. The letter was

dated 10/11/13. However I did not receive the letter until today

(10/23/13).

Looking at the address, it is directed to my attention, but lists

“ProHealth Care Medical Centers Oconomowoc”. While the street address

is otherwise correct, there is no such building. My assumption is that

the letter got transferred to Oconomowoc

Memorial Hospital and then resent back to my office at the Riverwood

Building in Waukesha.

I am writing you as an initial matter with 2 questions:

1)

Given that I did not get the letter until today

(10/23) would you be willing to give us 7 business days from today to

respond (as was originally offered in your letter)?; and

2)

Has Ms. [redacted] provided you with an medical

records authorization/disclosure form? Given the nature of her

complaint, the information that may be responsive may be protected

health information which we cannot disclose under HIPAA/Wisconsin

Law without, in this case, a medical release. If Ms. [redacted] would be

willing to sign such, I would be happy to forward the form to you. (In

that case we would need additional time to respond since we would need

to get the authorization back). If Ms. [redacted]

is unwilling to sign an authorization, we will still respond but our

response may be extremely limited and incomplete given the above.

Thank you for your understanding. I look forward to hearing back from you.

Risk Management Officer

ProHealth Care, Inc.[redacted]

Review: This is an official complaint against the Prohealth care medicall billing process. I have received the invoice from [redacted].

Patient Name: [redacted]

This is the 2nd incident that we are charged incorrectly, when I had visited the doctor for preventive care visit.

The first incident was on visit date of 17-August-2013 with Dr. [redacted] This was a preventative care visit. We called up the billing department to make a change. They came back in 3 days and said it was not a preventive visit. We checked with the doctor and her nurse, and they both confirmed that it was preventive care visit. We went back to the medical billing department and talked to the supervisor. They would be outright rude with us and keep threatening to send it to collection agency. For the first visit, we were charged $59.25 for so called "Professional/Clinic Services" under diagnostics eventhough it was the prevetive care visit. We paid $59.25 in order to avoid collection agency issues.

The second incident happend for visit on 12-Jun-15. This was not a doctor visit. This was just labs ordered that are to be performed as part of preventive care visit. We were charged $32.77 (visit # [redacted]). We repeated the same process. We called the billing department for the 3rd time, and talked to Paulene & her supervisor Sue. They sent it to re-coding but still kept sending the bills.

We are tired for dealing with this medical billing system, and want to lodge the complaint to resolve this issue.Desired Settlement: Adjust the charge of $32.77 and refund the amount of $59.25.

Business

Response:

Upon review of the medical records for patient [redacted] Guarantor ID: [redacted], I agree that an additional 99213 was not warranted. The charge has been removed and a refund will be forthcoming. For the second part of the review on the labs done on DOS 06/12/2015, our office contacted United Health Care as a corrected claim had been sent to them. United Health Care does not recognize screening codes as preventative so a corrected claim was sent with the preventative code added. The claim was applied to the deductible each time for both labs done that day. United Health Care admits that they did not process the second claim as a corrected claim but as “already processed” so no changes were made. They have agreed to reprocess the claim which can take up to 15 business days. This is not a guarantee of payment for the two labs done that day. There is a phone note in the patient’s chart specifically asking for one of the labs to be done as the patient was having symptoms and wanted to be sure everything was all right. Since this was a medical reason and not part of a preventative visit it may still be applied to the deductible. We will await the response from the insurance. The lab charges have been put back out to an insurance balance so the patient will not get a statement until the insurance has processed. We hope that satisfactorily answers the patient’s concerns. Sincerely, [redacted] Coder Team Lead [redacted]

Consumer

Response:

[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.]

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,

Review: I was billed $125.29 in addition to $175 for my $25 per visit co-pays for 7 PT visits at the ProHealth Care Muskego Clinic. Prior to my first appointment of 11-26-14, I called ProHealth Care and my insurance company, United Healthcare to confirm my coverage and to confirm my financial obligation. I was told by both entities that I would incur a $25 co-pay for each visit, nothing more, nothing less. I also looked at the Summary of Benefits and Coverage for my Plan where it states the same information.

After seven visits to the Muskego clinic, I received a bill for $125.29 from ProHealth Care for said PT. I paid my $25 co-pay at each visit so I was both surprised and frustrated when I received said bill. I called ProHealth Care to learn why I was being billed an additional $125.29 and was told that my PT treatment was billed as outpatient hospital services, not office visits. I then called United Healthcare and was told the claim was paid correctly per the billing submitted. I expressed my dissatisfaction as that is not what I was led to believe would be the case from both the provider and insurer, the exact reason I called each entity prior to making a single appointment. I was then told to contact ProHealth Care to see if they would submit a new bill. I talked to D** at ProHealth Care and he said they would not resubmit the billing.

I then spoke to [redacted] at United Healthcare and he told me the next step would be to request an appeal, which I did. My appeal was denied based on United Healthcare's belief they paid the bill correctly based on the submission. I am extremely frustrated as I attempted to be a good consumer of my insurance coverage and fulfilled my due diligence by making the phone calls prior to scheduling an appointment so as to avoid any billing surprises. Obviously, my efforts did not make a difference. Not once during my pre-appointment conversations, nor is it in black in white in my Summary of Coverage, is it mentioned that there would be additional fees if the PT is billed as an outpatient hospital visit. How would I ever know this could be a possibility if no one brings it to my attention? I have no idea how providers bill their services. I do not feel I should have been billed, and have paid under protest, the additional $125.29. I paid my $175 in co-pays for my seven visits. As soon as I received the bill, I canceled all future appointments without having reached my healing plateau. I now know to never use ProHealth Care as a PT provider. I do not understand how they can bill PT as an outpatient hospital service when other PT providers bill it as office visits. I was not in or at the hospital. I was at the clinic I go to for all of my medical appointments. Further, it was frustrating to receive the bill two months post my first appointment, yet was expected to pay it within approximately 3 weeks of receipt -- I did not pay it all at once as I let them know I was appealing it through my insurance company. It has since been paid in full. If I would have received it more timely, I would have canceled any PT appointments without incurring additional fees. This billing makes absolutely no sense to me and appears to me to be a rip-off. The very reason I inquired about prior to making a single appointment -- billing -- is what came back to bite me. While it's not a big dollar amount, it is not what I was told would be the case and is plain wrong.

Please note, I wrote my checks payable to ProHealth Care and contacted ProHealth Care about my billing concerns. Since the PT services were billed as outpatient hospital services, it makes me wonder which entity is the correct one to address my complaint to -- ProHealth Care or Waukesha Memorial Hospital.Desired Settlement: I would like the $125.29 additional billing -- over and above my co-pays -- to be refunded.

Business

Response:

I am writing to you on behalf of ProHealth Care Inc., to respond to your letter of June 10, 2015 related to Ms.

[redacted]. I have reviewed your letter and information which you had provided related to Ms.

[redacted]s June 9, 2015 complaint related to physical therapy services she received in 2014 at the Muskego

Clinic and provided by ProHealth Care's Outpatient Therapy Services.

Review: My son was referred to the clinic for head theropy from our doctor. We went to set up a free consulation with the new berlin office and we asked them to make sure our insuarnace would cover the costs. They checked and said yes it was covered completely and we would not have to pay anything out of pocket. we asked to double check which the supervisor checked and said yes we would not have to pay any type of co pay. this was witnessed by 3 other people. The theropists said the theropy would work and we wouldnt need to have the expensive helmet for my son. Well his head got even worse and we had to take him to a specialtist to get fitted for a cranial helmet for $4000. Now we recieve a bill for $501.39 for services they said we didnt have to pay and that didnt work but made it worse. I asked them about it but was told it was our problem. Real bait and switch to get us in the door for something that didnt work.Desired Settlement: I asked the bill for $501.39 be removed as this was a clear case of bait and switch to get us in for something that didnt work.

Business

Response:

As of this date, we have do not have a signed medical authorization that would allow us to disclose specific information. We have provided as much of a response as we are able at this time. We can provide a more complete response if we receive the information noted in the attached letter. I will forward the original to you today be US Mail as well.If you have any questions or need any further information, please do not hesitate to contact me. In addition if you receive a signed authorization you can forward that to my attention. Thanks[redacted]I am writing to you on behalf of ProHealth Care Inc., to respond to your e-mail of November 25, 2015. You e-mail forwarded the electronic submission made by [redacted] to the Revdex.com related to medical bills for care for his son. A. Need for Additional Information/Medical Authorization for Complete Response According to his submission, Mr. [redacted] has questions about medical bills which he states relate to therapy care that his son received at ProHealth Care. However Mr. [redacted] submission does not identify the name or date of birth of the patient, and he does not identify the dates of the care or charges he questions. It would be difficult to provide specific answers to Mr. [redacted]'s questions without more information.In addition Mr. [redacted]'s submission raises questions which in part relate to information that would be in a patient's medical and billing records. For example Mr. [redacted] raises questions related to a plan of care and therapy, discussions about that care and the scope of bills he has received for that care. Mr. [redacted] also raises questions about what he was charged and what is covered under his insurance. In order to provide a full and complete response to Mr. [redacted]'s concerns, ProHealth Care would need to be able to refer to and disclose portions of billing records and medical records for the dates of the care at issue. We would also need confirmation of the name and date of birth of the patient, as well as identification of the dates of care at issue. However at this time we are limited in what information we can provide to you in response to Mr. [redacted]'s questions. Under Wisconsin and Federal law, medical records and medical information within those records are protected and confidential. ProHealth Care is very diligent in protecting the confidentiality of our patient's health care information. As a result, without an authorization from Mr. [redacted] allowing us to disclose information regarding the care at issue to you, we are not able to provide a full and complete response to your November 25themail and Mr. [redacted]'s submission. If Mr. [redacted] wishes to authorize disclosure of this information to you, he would need to complete a medical authorization form. On December 29thwe forwarded a copy of ProHealth Care's medical authorization form to you. As of the date of this letter, we have not received a signed authorization from Mr. [redacted]. If Mr. [redacted] is willing to provide you with a signed medical authorization, he can use the enclosed authorization form (the same as what we previously sent) for that purpose. Mr. [redacted] would simply need to complete it to indicate that the records could be disclosed by us to you and the Revdex.com of Wisconsin. (This same document is available on the intemet at http://www.prohealthcare.org/patientguest-services-medical-records-request.aspx)...⇄ Mr. [redacted] should understand that if he does authorize ProHealth Care to release records or information to a third party like the Revdex.com, ProHealth Care cannot confirm or control how that third party will maintain, access, communicate or otherwise use the records or information once released. B. Response to Mr. [redacted]'s Submission While we cannot at this time disclose protected health information, we can at least provide you with some basic information about ProHealth Care's Outpatient Therapy Services billing practices that apply generally to ProHealth patients. Patients who receive therapy services through ProHealth Care's Outpatient Therapy Services are advised before receiving any therapy that such services are charged as hospital outpatient therapy services. Patients are advised that it is their responsibility to verify their insurance coverages, including therapy benefits, with their insurance providers. This information is communicated to patients in multiple ways. For example, patients who are going to participate in therapy receive a "welcome" letter Outpatient Therapy Services at the start of the therapy program. This letter reminds patients that it is their responsibility to verify the amount and nature of coverage for their hospital outpatient therapy visits with their own health insurer. In addition patients receiving outpatient therapy services at a ProHealth clinic location will first sign a "General Consent and Agreement to Pay for Treatment" form. The form tells the patient that it is up to them to confirm what health insurance coverage they have for the therapy services. The Agreement also asks the patient to acknowledge that if there is a portion of the bills that are not covered by their insurance carrier, that they would be responsible for payment of those services. ProHealth staff does not make representations to patients about the nature or extent of their insurance coverage. If a patient raises questions about their coverage, ProHealth staff refers that patient back to their insurance company. Given the variety of health care plan coverages, and the fact that staff would not have knowledge about the specifics of particular patient's coverage or billing history with their particular provider in a particular year, ProHealth staff can only suggest that the patient contact their insurer if they have questions about what might be covered. C. Summary In conclusion I want to reiterate that we are unfortunately limited in our ability to provide you with a complete response to Mr. [redacted]'s submission at this time. In order to respond more fully we would need additional information from Mr. [redacted] (the name and date of birth of the patient and specific charges at issue). In addition, ProHealth Care is significantly limited in our ability to answer Mr. [redacted]'s questions for you without an authorization allowing us to disclose protected health information at issue to you and the Revdex.com of Wisconsin. What we can confirm for you at this time is that ProHealth Care has established practices and materials to consistently communicate to our patients that ProHealth cannot advise or confirm the nature or scope of their individual health care coverage. ProHealth tells patients that it is a patient's responsibility to know the extent of their insurance coverage, and that the patient should raise any questions about coverage with their insurer. On behalf of ProHealth Care, I appreciate your time and consideration of this letter. If Mr. [redacted] does provide a signed medical authorization, we would be happy to promptly provide you with more detail. I will enclose a copy of the authorization form with this letter. Please let me know if you have any questions and I will be happy to respond. You may reach me at (262) 928-2124, at [email protected] at the address noted below. Thank you for your time and consideration of this letter and our position. [redacted] Vice President of Risk Management & Risk Management Officer ProHealth Care, Inc.

Consumer

Response:

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 assist us in bringing this matter to a close, we would like to know your view on the matter.]

I have faxed the medical request to the hospital. My son's name is [redacted] dob [redacted]. The fact of the matter is we would not have done the theropy unless they told us it was compeltely covered by insurance. we asked them at the desk to review and both the front office and the supervisor said it was completely covered by insurace and we had no out of pocket. Now it also states at their office to ask for an estimate right there. Since this complaint I was sent to collection and have paid the full amount in question but this really should be refunded to me as it was a complete bait and switch. Regards,[redacted]

Business

Response:

If Mr. [redacted] would like us to provide to you a full and complete response, he would need to complete a medical authorization specifying that we can release information to you and to the Revdex.com. We also wanted to make sure that Mr. [redacted]understood that if he does authorize ProHealth Care to disclose confidential information to the Revdex.com (or any other 3rd party), we cannot confirm or control how that 3rd party will maintain, access, communicate or otherwise use the records or information once it is released to them, including that the 3rd party may make the information public. In Mr. [redacted]’s January 13th response, he states that he has now provided a signed authorization for the release of his son’s records to you. I did not receive a copy of any authorization. However after receiving the January 13th response, I checked with our medical records department. It appears that Mr. [redacted] did send a signed medical authorization, but he did not fill out the part asking him to identify who ProHealth Care is authorized to release information to. I believe that our medical records department would have returned the authorization to Mr. [redacted] because the form does not say who can receive the information and records. So at this time ProHealth Care is still unable to provide a complete response. We would need a medical authorization allowing us to disclose records of information to you and to the Revdex.com. I can resend another copy of this form to you if you need one. This authorization form can be downloaded at: http://www.prohealthcare.org/patient-guest-services-medical-records-request.aspx Then in the section titled "Disclosure of Health Information To:" Mr. [redacted] should indicate that the information and records can be released to you and the Revdex.com (assuming that he wants us to disclose information to you). In addition, it would be helpful if Mr. [redacted] could return the authorization, if he does wish to complete one, either to you (so that you can forward to me) or to me directly (via email, fax or whatever method is easier for him). Once again, we want to make sure that Mr. [redacted] understands that if he authorizes us to release records and information pursuant to an authorization form, ProHealth Care cannot control how the records and information is used once released. If Mr. [redacted] has questions about how the Revdex.com would use, disclose or communicate the records or information (including whether it would be become public record in some way) he would need to direct those questions to you or the Revdex.com. I would be happy to answer any questions Mr. [redacted] had about that issue. In addition, I can advise you that we have reached out to Mr. [redacted] directly and offered to discuss his concerns and questions with him directly. I am happy to answer any questions you may have as well. Your January 13th communication asked us to respond within 10 days. I will be happy to provide another response by January 23rd, but without a completed medical authorization we will still be unable to fully respond to Mr. [redacted]’s submission to you. Thank you for your time and review of this email. Please feel free to contact me with any questions. [redacted]V.P. Risk Management &Risk Management OfficerProHealth Care, Inc.N17 W24100 Riverwood Drive, Suite 375Waukesha, WI 53188Direct: (262) 928-2124Cell: (262) 443-3443Fax: (262) 953-8733E-mail: [email protected]

Review: Recently, I found out there is a collections posted on my credit report affecting my credit. A debt who was sent to collections under my ex-spouse name was subtly passed on to me by the hospital. It is my understanding that it was posted to collections sometime in early September of 2012. Later in the year, I requested the hospital to be the guarantor for future visits. It seems they changed the name on the existing account, instead of creating a new account and assign to my son's patient account. Due to the name change, the collections was passed on to me, which happened due to the incorrect procedure in assigning the guarantor for going forward.

I contacted the billing department and talked the representative, not only she was unhelpful, also laughing at me for requesting to talk to authorities on the hospital side. I also left a voice mail for the supervisor, she returned the call but putting the blame on me and not accepting the mistake of how the collections was transferred to me.

I was not only unaware of this until now, it also affected my credit and all things related like insurance premiums etc.Desired Settlement: I would like Revdex.com to work with hospital to understand their procedural issue and remove the collections from my credit report. It is not acceptable to pass on collections without even notifying me. I had no control over how they updated the information on the system. This would not have happened if they created a new account and linked to the patient account. Thank you.

Business

Response:

This letter is to confirm that we have received an Inquiry from you regarding a consumer complaint filed by [redacted] concerning Pro Health Care - Medical Associates. Your letter was directed to an individual that no longer is working at Prohealth Care so unfortunately your letter was not delivered to me until today.