Riverwalk OB/GYN

August 3, Re: Response to Complaint Dear Revdex.com, Thank you for advising our office of the complaint filed with your department from one of our patientsThe patient has complained because a refund has not been issued for a credit on their accountIt is out Standard Operations to process refunds according to certain steps to ensure that the patient will not later receive a bill for our services and have to return the money back to usWe first thoroughly investigate the details of the accountWe contact insurance companies, research explanation of benefits, and do an audit of the accountThe audit of the account entails us looking at every charge and every visit making sure all adjustments have been made, correct billing protocol has been followed, that there are no other pending claims or upcoming appointments, and the proper coding is on the claimsIn doing this process we sometimes must leave messages and wait for the return call of insurance companiesThen one the claim is investigated it may be necessary to appeal certain charge to the insurance company if any of the claim was deniedThe appeal process for a claim can take up to 60-days or moreOnce the appeal is complete if one has been filed, then we prepare account to be given to the Administrator for approvalThe administrator once approved will send the accounting team to process the checkThe patient will be refunded once all verification and processes have been exhaustedThe appeal was filed with the insurance July 21, Depending on the status of the appeal a full refund will be granted to the patient [redacted] Practice Administrator

Complaint: ***
I am rejecting this response because:
Dear Revdex.com,
The practice administrator attempts to minimize this
complaint by recycling the “standard operations” response, however, allow me to
detail how Riverwalk OB/GYN’s lack of standard protocol for claims processing
and refunds, blatant disregard for ethical consumer practices and egregious
customer service that has resulted in over months of dispute
My patient experience at Riverwalk OB/GYN began in Insurance
information was collected prior to the first appointment, claims were filed with
insurance appropriately, and our out-of-pocket cost shares were paid in a
timely mannerClaims filed with Cigna for dates of service and processing
include: 08/18/(processed 08/23/16), 08/03/(processed 08/06/16), 07/20/
(processed 07/30/16), 05/25/(processed 05/21/16), and 06/12/(after my
deliver- processed 06/24/17)Each of these claims were filed and processed
within 3-days from date of serviceBased on the expeditious filing and
processing of these claims it can be assumed that the practice was aware that I
had active insurance coverage
When I became pregnant in late 2016, per Riverwalk OB/GYN
policy, I was required to pay anticipated cost for delivery prior to my 32-week
prenatal appointmentPayments were made to Riverwalk OB/GYN by credit card for
$2,073, in advance of my delivery and in agreement with practice procedures to
be applied toward my deductible and cost share
My daughter was born *** *** ***Due to our
daughter’s extensive hospitalization and subsequent treatment, our family
out-of-pocket maximum of $11,was met in March Once the out-of-pocket maximum
is met, our plan states that 100% of covered, in-network services is paid by
insurance with $patient responsibilityIn March 2017, after organizing medical
bills and explanation of benefits, we realized that Riverwalk OB/GYN had not
yet filed a claim for delivery and maternity care, resulting in our deductible being
applied to other providers, in the order that claims were received and
processed
Riverwalk OB/GYN’s office was immediately notified by
telephone that a claim had not yet been filed for delivery and maternity
servicesThe front desk clerk advised that a third-party billing company was
charged with all claims processing and I was provided their numberIt was
expected that I initiate and track the correction of this billing error
After days of repeated calls, reaching automated messages
stating all voicemail accounts were full, I made contact with ***, an
account specialist with the billing companyI explained the oversight,
provided specific account information, dates of service and insurance
information*** rationalized that a claim was not filed for this date of
service because I had requested to be “self-pay”I clarified that I indeed had
current insurance coverage, had done my due diligence in providing and keeping
this information updated, evidenced by the previous claims that had been filed and
paid to this provider for dates of service before and after my delivery, and
supported in that obligatory prepayment reflected an insurance contractual rate,
not reflective of a “self-pay” rate
*** asked what I would like the billing company to do
nextI stated I would like a claim filed through my insurance and a refund of
my prepayment to be processed immediately, as our out-of-pocket maximum had
been met and we would have $patient responsibility, no matter the status of
the claim
I waited approximately weeks before reaching out to ***
for an update, bringing us to early April During this week period, no
claim was filed through my insurance on behalf of the practiceAgain, I
reached full voicemails and was unable to reach *** at her personal line nor
the billing company at their general lineI contacted Riverwalk OB/GYN to
report the difficulties I experienced making contact with the billing companyThere
did not seem surprised by the difficulty I was having reaching a live person at
this billing company and insisted only the billing company could help meI
advised the staff again, that a claim had still had not been filed for my
delivery and I was due a refundI was told I would receive a return call from
the office manager to discuss my issues and I was so relieved to finally have
some help resolving this matter, because surely the office manager would be the
person that could access billing directly and advocate for correcting this
issueAstonishingly, I failed to receive a call back from the office manager
that day and have yet to hear from her, months later
For the next months, I called the billing company
wondering why a claim still had not been filed and was told it had been
“escalated”I would immediately call the practice to report the still
unresolved issue and was put on hold for over minutes at a time, only to be
connected to the office manager’s voicemail when she was suddenly unavailable or
on vacationI made over calls each month in attempt to correct this
situationI spent countless hours on the phone, either on hold or leaving
messages for an office manager who till this day has not returned one phone
call to acknowledge the oversight or explain these “standard operations” they
are followingWe have been ignored and avoided by the practice manager and
dodged by the out of state billing company that refused to provide their company
name, further contributing to the growing mistrust of the practice and billing
company’s intent on refunding our payment
In June request for statements of account and
reconciliation were made by myself and my husband on my behalfWe were advised
that an itemized statement would be mailed outAs of August 9, 2017, we have
not received an request itemized statement, in violation of Texas Occupational
Code, Subchapter H, Billing, Sec(e) “a physician shall provide a
patient with an itemized statement of charges for professional services or
supplies not later than the 10th business day after the date on
which statement is requested
Additionally, in mid-July, we were contacted by *** ***, from the billing company, urging us to accept a partial refundMs
*** promised to begin the refund process immediately if we accepted the
agreed upon amountWe declined the partial refund, questioned why a claim had
still not been filed, and reminded her of our $liability for any claims
processed after March Once again, we provided information from our
insurance in the form of emailed plan documents, to prove that we were not
responsible for out-of-pocket expenses through the end of the plan yearAfter
Ms*** understood that we would not be accepting a partial refund she then
threatened that although we don’t have a financial obligation, she could not
guarantee that a refund would be issuedShe stated that the refund process is
initiated by the office manager; the same office manager that until her email response
to our Revdex.com compliant, had failed to even acknowledge me as a patient
On July 21st, a claim was filed for delivery and
maternity care on behalf of Riverwalk OB/GYN, almost months after the date of
service and months since I began my efforts to recover my overpaymentThe
claim was denied on July 24, for untimely filingA second attempt was
filed on July 25, 2017, denied same day as duplicate serviceTo my
understanding, an appeal has been submitted, though proof must be provided that
there was an attempt to file timely, of which there is no evidence, in order to
warrant reconsideration
State law mandates that overpayment to physicians be
returned within days after determining patient has overpaidThe billing
office and practice manager, by way of voicemail, were provided information to
support a $patient responsibility should a claim be filed for services, demonstrating
their prior knowledge of overpaymentThe neglect in correcting such as obvious
mistake suggests an effort to discourage us from seeking a refundThe complete
lack of acknowledgement of our complaints and effort to correct this error, then
bullying us to accept a partial refund is simply unethical
The office manager stated “depending on the status of the
appeal a full refund will be granted”The status of the appeal should have no
bearing on the refundRiverwalk OB/GYN is a network provider who has failed to
meet the contractual obligation of timely filingOur $patient responsibility
has been communicated to all parties repeatedlyTherefore, unless the intention
is to fraudulently balance bill me in light of expected denial of this claim, a
refund should have been initiated at the time they were notified the
out-of-pocket maximum was met, over months ago
Should the billing office or practice manager have
acknowledged our concerns and complaints sooner, they may have met their timely
filing obligationInstead, I have yet to hear from the office manager with
whom I left over voicemails and messages via front desk personnelFact:
Her response to this complaint is the very first response we’ve received from
this office manager during this month ordeal
Riverwalk OB/GYNs and their billing company’s irresponsible
business practices have contributed to undue stress and wasted resources in an
attempt to recover our refundIt’s obvious that lack of responsiveness to
their fiduciary responsibility and lack of transparency in their standard
procedures has bred mistrustPractitioners should be held to the same
standards of business as any other companyI cannot imagine that any other
business would deem it acceptable to refuse a refund citing “procedures” they
themselves fail to follow in the face of irrefutable proof that a refund is due
has been established.
Thank you for your time and consideration,
*** * *** ***

August 3, 2017 Re: Response to Complaint Dear Revdex.com, Thank you for advising our office of the complaint filed with your department from one of our patients. The patient has complained because a refund has not been issued for a credit on their account. It is out Standard Operations to process refunds...

according to certain steps to ensure that the patient will not later receive a bill for our services and have to return the money back to us. We first thoroughly investigate the details of the account. We contact insurance companies, research explanation of benefits, and do an audit of the account. The audit of the account entails us looking at every charge and every visit making sure all adjustments have been made, correct billing protocol has been followed, that there are no other pending claims or upcoming appointments, and the proper coding is on the claims. In doing this process we sometimes must leave messages and wait for the return call of insurance companies. Then one the claim is investigated it may be necessary to appeal certain charge to the insurance company if any of the claim was denied. The appeal process for a claim can take up to 60-days or more. Once the appeal is complete if one has been filed, then we prepare account to be given to the Administrator for approval. The administrator once approved will send the accounting team to process the check. The patient will be refunded once all verification and processes have been exhausted. The appeal was filed with the insurance July 21, 2017. Depending on the status of the appeal a full refund will be granted to the patient. [redacted] Practice Administrator