San Clemente Internal Medical Group

Review: After an Emergency Room visting in April of 2013, this doctor's office billed my insurance with the incorrect billing codes. I've contacted the doctors several times trying to get them to submit the correct codesm (outpatient) to my insurance company and they have not done so. Instead, they have sent me to collections and are now claiming that they can't do anything even though they created the problem in the first place.Desired Settlement: I am asking this doctor's office to resubmit the billing to my insurance company for payment, and remove my account from collections as this was a billing error on their side. I would also like a letter from the doctor's office stating it was a billing error on their end so that I can work with creditors to restore my impacted credit rating since I maintain perfect credit and have never had a single late payment in my entire credit history.

Business

Response:

The Customer was seen by our Physician on April 1, 2013 and April 2, 2013 in the hospital setting. Insurance was billed and responded on April 17, 2013 with an amount falling to deductible and the balance being patient responsibility as we are out of network providers. At no time did the insurance company indicate that we had billed inappropriately, which they would have had that been the case. In June of 2013 I received a message from the Customer that they were surprised regarding the bill. I left a message on their cell phone to check with their insurance to see about having the bill reconsidered due to our out of network status. We actually send an example of how to request a reconsideration with a bill that falls completely to patient responsibility as it did with this Customer. I did not hear back from anyone and sent the account to collections in September of 2013. On December 29, 2014 the customer called stating they had spoken with the insurance company and that we had billed with the wrong code. I called Unitedhealthcare and reviewed the claim status. I asked if there was a billing error and was told no, the patient had an amount due for their deductible and the balance was their responsibility as we are out of network providers. I asked if we were to rebill with different place of service code would that change the outcome and was told that it would not as the patient had a deductible amount that was their responsibility regardless of the place of service. I was also told that if we rebilled the claim would be rejected as it was previously processed and now closed. In addition we did make an offer in compromise basically cutting the bill to less than half the amount owed to resolve this issue which the Customer declined. That offer in compromise is now no longer available. Our Physician remains unpaid to date for his services rendered in April of 2013.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

I was taken to the Emergency Room on April 1st, 2013 as I was having stroke symptoms and was treated for outpatient services while undergoing monitoring and tests based on my symptoms. The hospital that I went to was an in-network provider for my insurance carrier (United Healthcare). I was assigned this doctor in the emergency room who was providing outpatient services. Several months after my emergency room visit, we received a bill from our insurance provider telling us that we were responsible for the bill because the doctor was out of network and had billed us for inpatient services. I explained that the service provided was from an emergency room visit and I did not have a choice of doctor. At that time, my insurance company told me that the doctor had billed them incorrectly and needed them to correct the billing using inpatient billing codes rather than outpatient. After contacting the doctor's office and asking them to resubmit the billing as outpatient, I assumed the matter would be resolved.

Review: Medical services rendered on May 11, 12,and 13, 2012 in the Saddleback Memorial hospital by a doctor from San Clemente Internal Medical Group who at the time was part of the Cigna Medical Insurance network. After receiving payment from Cigna, San Clemente Internal Medical Group was not satisfied with the amount Cigna paid and therefor is now claiming they were not part of Cigna and is billing for additional funds. At no time did their doctor who was on call state he was not part of the Cigna network prior to rendering services in the hospital.Desired Settlement: I would like the continuous billing for these services stopped immediately.

Business

Response:

We are in receipt of your correspondence dated April 14 and April 28. Kindly address any future correspondence to my attention. For some reason you sent your correspondence to the attention of our IT Manager.

It appears to me that the patient not only contacted you, but that he did as we asked him and also contacted his insurance company to request that they reprocess his claim and pay it at the out of network benefit rate. The patients insurance company contacted me on 4-25-14 and is working to get his claim paid as requested at the out of network rate. The reason we set the bill to patient responsibility is to get the patients assistance in getting his claim paid appropriately by his insurance company , which is what is now occurring. In my experience it often than not takes the subscriber requesting claims reprocessing to get the insurance company do their part.

Should you have any further comments please do not hesitate to contact me at your convenience.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

The statement made that I am working with this doctors office to assist with payment by my insurance company is NOT TRUE. I have contacted my insurance company and they have taken action against the doctors office as they are trying to recapture the difference between what the insurance company paid and the charges for their services through me even though they were under the insurance umbrella that the participating hospital.

In other words, their response to you is a lie.............

Business

Response:

I do not believe that I indicated that the patient was working directly with us, rather that he had contacted his insurance company as we requested.