Rocky Mountain Spine and Disc

DRJOHN AS***, DCSOUTH SHIELDS, A1-3 FORT COLLINS, CO 80521(970) 682-2667 FAX (970) 672-8662DRCARLA I*** *** ** WEST 37Th STREETLOVELAND, CO 80538 (970) 663-4494(970) 663-FAX January 5, 2016Revdex.comSCounty Road 5, SteFort
Collins, CO 80528RE: ***, *** ID # *** To Whom It May Concern:The following shall constitute our official response, in regards to the complaint by *** ***. Mr*** states that our office "apparently never submitted a bill to Medicare," yet subsequently states his payments were denied, clearly contradicting his assertion of charges never being submitted to MedicareWe have provided him with a copy of processed charges from *** ***, the billing clearinghouse, which shows with extreme detail the exact dates, ID number, and charges which were sent to MedicareYou can see from our billing staff in an email (attached) that they have provided this for Mr*** on multiple occasionsMy billing staff has exceeded our responsibilities with regard to submission of Medicare bills on Mr***'s behalfThey have submitted to Medicare multiple times, provided proof of submission multiple times and I have explained we have no control over their payment multiple times, only to be met with hostility due to Medicare's decision to deny his services. Our office has never received any request from Medicare regarding "missing information." It is not an uncommon request from any insurance company for follow up information, yet none was ever received by this office regarding Mr*** and no evidence has ever been provided by Mr*** that this was requested or stated by Medicare or their administering agent. Mr*** signed an Advanced Beneficiary Notice (ABN), which is required by Medicare to be signed by any patient who receives services, which clearly states that "charges are paid at the discretion of Medicare part B and are based upon their interpretation of medical necessity." While we can understand Mr***'s frustration, it is out of our control whether Medicare reimburses himThese inconsistencies by Medicare are the exact reason we are non-participating and do not accept assignment from MedicareEvery patient is aware of our "non-participating" status with Medicare, which is why they must pay for services and receive reimbursement from Medicare, at their discretion. Mr*** claims I "got angry and said (I) would call him." This simply never happened It is Mr. *** who lost his temper (on multiple occasions) and said he would call our office to schedule his future appointmentsI am not in the business of getting "angry" with patients and I do not call patients to schedule their appointmentsIt is a patient's responsibility to schedule and use their appointments as prescribed, as stated in his signed Office PoliciesMr*** still has two visits which he may use at any time in our officeI can only make the assumption that he may have felt uncomfortable coming back in after his loss of temperHis signed Office Policies which are attached state that should he discontinue his treatment plan, any discounts (which Mr*** did receive) would be voidIn this scenario, Mr*** would actually owe our office additional monies for services provided, yet discountedHe is welcome to utilize his last visits at any timeHe need only call to schedule his appointment. His signed Office Policies also state that we are not responsible for whether a claim is paid by an insurance company but will resubmit one time, if necessaryAs stated above, my billing staff has provided services above and beyond thatThe enclosed documentation will provide evidence to the above-mentioned factsWhile Mr***'s frustration is valid, it is unjustified and unwarranted toward me and my staff. Regards John A S***, DC Enclosures:Signed Office PoliciesSigned ABN form Copy of Email from billing department Copy of *** *** claims processing

ROCKY MOUNTAIN SPINE & Disc DR. JOHN A. S[redacted], DC 1302 SOUTH SHIELDS, A1-3 FORT COLLINS, CO 80521(970) 682-2667 FAX (970) 672-8662DR. CARLA I[redacted]. DC 340 WEST 37TH STREETLOVELAND, CO 80538 (970) 663-4494(970) 663-9458 FAX January 28, 2016Revdex.com8020 S. County Road 5, Ste. 100 Fort Collins, CO 80528RE: [redacted]ID # [redacted]To Whom It May Concern:The following shall constitute our final response, in regards to the additional concerns by [redacted]. We have provided Mr. [redacted] and the Revdex.com with a copy of processed charges from [redacted], the billing clearinghouse, which shows with extreme detail the exact dates, ID number, and charges which were sent to Medicare. Mr. [redacted] is incorrect in his statement that claims were not processed as of December 2015 and we provided him evidence of that, including [redacted] print outs which explicitly state "Date Received 8/21/2015 8:00:08 AM." Mr. [redacted]'s perpetual insistence that claims were not submitted simply makes no logical sense. It is proven incorrect. Mr. [redacted] states claims were denied due to lack of patient notes (which would indicate submission by the office and processing by Medicare.) Patient notes are never included with digital claim forms. This statement illustrates the lack of understanding Mr. [redacted] exhibits as it relates to the billing process. We bill insurance companies daily, digitally. No notes for him have ever been requested of this office by anyone, including Mr. [redacted]. Our office has never received any request from Medicare regarding "missing information." It is not an uncommon request from any insurance company for follow-up information, yet none was ever received by this office regarding Mr. [redacted] and no evidence has ever been provided by Mr. [redacted] that this was requested. If this request had been made, we would have sent medical records/notes to Medicare. Mr. [redacted]'s statement that missing information "could be medical necessity notes" sounds more like someone's assumption or guess, rather than a concrete explanation. He stated he "learned from Medicare if a statement of medical necessity is not included with the claim — even valid claims will be denied" again makes no sense. There is no such thing as "statement of medical necessity". If an insurance company wants to validate medical necessity, they will request the provider's notes. It is done no other way. Mr. [redacted] signed an Advanced Beneficiary Notice (ABN), which is required by Medicare to be signed by any patient who receives services, which clearly states that "charges are paid at the discretion of Medicare part B and are based upon their interpretation of medical necessity." It does not state that this is based on having a "statement of medical necessity". Again, we have no control over Medicare's payment or its interpretation of medical necessity.  Mr. [redacted] is requesting a refund for services that he requested and received. Mr. [redacted] was made fully aware of "covered" (at the discretion of Medicare) and "non-covered" services.  We understand that he wants Medicare to reimburse for services rendered, but as we explained to him prior to any rendered services; that is not up to us. Mr. [redacted] states that we said we are "Medicare approved." There is no such thing as "Medicare approved" any more than "Medicare unapproved". A provider is either "participating" or "non-participating." We are non-participating, which means we do not accept assignment from Medicare. A patient pays us for services, we bill Medicare and if Medicare reimburses, the reimbursement goes directly to the patient at Medicare's discretion. We never tell a patient what Medicare will pay; we state what is a covered service and non-covered service and give an estimated reimbursement. A signed ABN acknowledges this conversation between patient and staff or provider. We do not provide reimbursement to a patient when Medicare does not pay. This is why patients sign an ABN, so they are aware they may not get any reimbursement. Medicare forms are standardized HCFA Form 1500 and are sent in that form digitally to our clearing house [redacted] who then checks the forms for any discrepancies and sends them to the insurance company. The statement that we did not use the "proper universal insurance claim form" is incorrect and again makes no sense. All insurance billing is done digitally through an insurance clearing house. The only other way to bill insurance is standard HCFA forms printed and mailed, only if required by that insurance company. If a patient asks for proof of billing (which has never before occurred) we do not provide HCFA forms because we never have a printed HCFA form (that is all digital); we have verification from [redacted] that the claims were uploaded and in process. We will not oblige the refund request of Mr. [redacted], as it is Medicare's responsibility to reimburse based upon their determination. In addition, Mr. [redacted] was given discounts which are void once he discontinues care, according to his signed Office Policies. I believe my mistake was not immediately discharging Mr. [redacted] when he came to my office and made a scene. This happened three times. I really thought once he saw the forms proving Medicare had been billed, he would calm down and see his frustration directed at our office was wrong and continue his care. After our best attempts to inform both Revdex.com and Mr. [redacted] without success, he is now discharged from our practice. We have included his discharge financials as an enclosure. According to his signed Office Policies, "In the event you discontinue or are discharged from care for any reason, your financial responsibility is for the treatments you have received. All outstanding fees become immediately due and payable at full service price: including diagnostic x-rays." A financial settlement balances services rendered at full service price vs payments made by the patient. As a discharged patient, Mr. [redacted] would owe our office a balance, in lieu of not using two of his remaining visits due to the discounts which are voided due to discontinuation of services. His signed Office Policies are again enclosed. On a side note, I must question the motive for such vitriol coming from Mr. [redacted]. We found him to be very pleasant to work with, prior to his increasingly hostile appearances in our office. He had stated to my staff member at one point that there were inquiring minds at home, pressuring him about reimbursement. I can only imagine the stress that must create. With that said, he and I both know who instigated the hostility and we both know he is far from the "senior citizen living on a fixed budget" in which he paints himself to be. I have many patients whom live on a fixed budget. They cannot afford to prepay their care plans nor can they afford to have a second residence in another state. Attempting to create sympathy due to your financial situation when it is not part of the facts is unwarranted and unfair to those who truly are on a "fixed income." Over the years, 1 have had several patients whom have had their treatments denied for reimbursement from Medicare. Although it is uncommon, it does happen. Unfortunately, Mr. [redacted] is the only patient who has displayed such intolerance and outright anger over the matter. It is our wish that Mr. [redacted] direct his frustrations more towards the broken system which won't cover the treatment which helped him so profoundly, and less towards the provider who did. We run an upstanding practice and have served a tremendous number of individuals in this community and we will not tolerate Mr. [redacted]'s slanderous accusations and lies. It is very difficult to continue to explain the process of billing Medicare when that process is so profoundly misunderstood by the recipient. We have given every effort to help him understand the billing process. Any additional communication containing inflammatory and slanderous wording will be forwarded to our legal representatives. Regards, John A S[redacted], DC Enclosures: - Signed Office Policies- Signed ABN form- Copy of [redacted] claims processing-Copy of Discharge Financials