SETMA L.L.P.

Southeast Texas Medical Associates LLP response to complaint Our staff have spoken with Mr [redacted] regarding his daughter’s testWe applied the event monitor at our office and it gets sent in for readingHe is required to pay his 10% which is $The bill is in appeal and he will owe nothingEven if the appeal is denied, he will not have to pay anythingWe have never had this company deny any insurance and this is the company we use for all our event monitors According to [redacted] , Director of referral/billing department she has called himShe talked to him on 10-10-2014, he wanted to communicate via e-mail, because he had a meeting that day She told him that she would call him back after she found out what or who could help him After she checked with Dr [redacted] ’s pod and talked to ***, she called him back and left him and extended message letting him know that he needed to talk to [redacted] at Dr [redacted] ’s pod [redacted] the nurse in Dr [redacted] ’s pod who has been working the appeal with his insurance company will also call him Sincerely, [redacted] ***, RN MSN Director of Operations Southeast Texas Medical Associates, LLP

I would like to apologize for how this situation was handled [redacted] actually works with an Infusion company SETMA partners withShe is an employee of themI will personally share with her supervisor about this complaintSETMA's Director of Clinic Coordination will as well discuss the situation with [redacted] and let her know that it is not our practice to discuss situations with patients in the waiting area [redacted] will be made aware of how to appropriately deal with patientsI am aware that we have had difficulty with her insurance company and the infusion center making sure there was proper authorization to proceed so I can understand frustration on the patient as well as the infusion staff as they have been trying hard to get this taken care of

Complaint: I am rejecting this response because: Sincerely, Richard Coward Is it usual business practice to charge for both an outpatient office visit and a wellness visit at the same time? Their response to me sounded like a politician talking in circles and saying nothing Their charge for the pneumonia shot was nearly $more than what is charged in other places They give me a shot and also charge me for giving me the shot The nurse didn't take minutes and they charged $ Lidocain is usually used for numbing the site where an injection is to be given I am nearly years old and have never had lidoain included in an injection As for the doctor's code, I spoke to my doctor about the issue before I left I was told who was doing the coding and the charging off As I said in my complaint, it is not the doctor I have known him for many years and consider him a friend SETMA needs to get its act together, admit that they have messed up, and fix the problem Does Larry know about this?

This letter is in reference to a Revdex.com of Southeast Texas Beaumont complaint ID received by Southeast Texas Medical Associates on Monday March 2nd, 2015.We received a request from Ms [redacted] on Friday, January 9th, There are steps that we follow in order for a refund to be completed and it usually takes to weeks The time will vary depending upon on the date we received the over payment, pending insurance reimbursement and other balances within the account This refund should have been completed and received by Ms [redacted] on Friday, February 20th, to allow the maximum allotted time of weeks Due to unforeseen reasons within the Accounts Payable Department they fell behind and this refund was not mailed until February 23rd, We apologize for any inconvenience that this may have cost the patient Please let me know if you have any further questions or need additional informationThank you, [redacted] C [redacted] [redacted] C [redacted] , CPCDirector of CBOBilling, Collections, Referrals & Front OfficeSoutheast Texas Medical Associates, LLP

Medicare allows an annual wellness visit yearly which is NOT a physicalIt looks at the preventive measures needed such as immunizations etcfor the 1/31/visit there was no annual wellness visitThere is a note in the chart that says the patient did not wish it to be done and it states do not
chargeI do not see in the record where it was billed at this visit. As a matter of reference, Medicare wellness can be done at the same time of a sick visit as it is not, as mentioned, a physical examPrevnar is the pneumonia vaccine that was givenThere are different pneumonia vaccines that are now recommended for patients to havePrevnar is the newest and covers different strains than the regular pneumonia vaccinePrevnar is more expensive, which is not a billing problem but a problem with the cost of pharmaceuticalsLidocaine is given when an antibiotic is given as those injections are very painful so a bit of lidocaine is mixed with the injection to make it be more tolerableThis is common practice but we can make sure and inform patients this has been added for their comfort At SETMA the doctor enters any billing codes they use during the visitThe billing office just complies these and sends to the insurance companyThe billing falls with the provider

Complaint:
I am rejecting this response because:
Sincerely,
Richard Coward Is it usual business practice to charge for both an outpatient office visit and a wellness visit at the same time? Their response to me sounded like a politician talking in circles and saying nothing. Their charge for the pneumonia shot was nearly $more than what is charged in other places. They give me a shot and also charge me for giving me the shot. The nurse didn't take minutes and they charged $55. Lidocain is usually used for numbing the site where an injection is to be given. I am nearly years old and have never had lidoain included in an injection. As for the doctor's code, I spoke to my doctor about the issue before I left. I was told who was doing the coding and the charging off. As I said in my complaint, it is not the doctor. I have known him for many years and consider him a friend. SETMA needs to get its act together, admit that they have messed up, and fix the problem. Does Larry know about this?

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 12204204, and find that this resolution is satisfactory to me
Sincerely,
*** ***

The complaint was reviewedA call was made to Mr*** and an apology was made to himHe was offered to see other providers within SETMA and to chose a different primary care physician that would better fit his needsMr*** responded positively and will be called again this week for follow up
to see if he made his decision about another providerThe patient has a contractual agreement with insurance company to pay co paysBy regulations SETMA is obligated to collect copays for office visits when the patient are seenAs of this time we cannot provide credit on the account as the two visit involved being seen by the providerIf the patient would have left before being seen we could refund the copaySETMA CEO has reviewed the complaint and due to confidentiality nature I am not at liberty to discuss what occurred between him and Dr *** however know that this has been discussed and dealt with in an appropriate manner.Submitted by*** ***, RN MSN Director of OperationsSoutheast Texas Medical Associates, LLP

I would like to apologize for how this situation was handled*** actually works with an Infusion company SETMA partners withShe is an employee of themI will personally share with her supervisor about this complaint. SETMA's Director of Clinic Coordination will as well discuss
the situation with *** and let her know that it is not our practice to discuss situations with patients in the waiting area*** will be made aware of how to appropriately deal with patientsI am aware that we have had difficulty with her insurance company and the infusion center making sure there was proper authorization to proceed so I can understand frustration on the patient as well as the infusion staff as they have been trying hard to get this taken care of

The Medicare wellness exam is relatively new and can be done yearlyBecause it is not a physical exam but a review of records and preventive measures it can and often is done with a sick visitThese are the rules Medicare allows or we would not be able to bill for it at the same timeDr [redacted] is acutely aware of this and encourages all providers to get the wellness exam done when it is appropriate for each Medicare patient and to do this early in the year if possibleEach insurance company has a contractual agreement with physiciansThere are contractual charges that are adjusted off that you nor the insurance company is not responsible for payingThese are shown on the estimate of benefits statement you get from your insurance company? That is the same with the prevnarIt is very expensive for us to purchaseWe do not compare prices with other entities but come up with reasonable and customary charges and the adjustments as well which are approved by the insurance companies through the contractual agreementEvery injection has an injection fee associated with itThat is standard? and allowed by the rules set by the medical boardLidocaine mixed with an injection (not a topical rub) is often added to the ? antibiotics to lessen the painI am sorry they did not tell you before giving you the injectionIt was? not done to? cause you any grief with billing but to make it less painful at the injection siteEvery provider enters the codes they wish charged for at the visitThe billing office only looks for visits that do not have codes attached and then they must get with the provider to see what they wantthey review records to ensure there is proper documentation to support the codes used for billingThey cannot and do not make up the codesWe have people that are assigned to review charts and ensure the documentation matches the billing codesInsurance companies also do thisThey come to our site and do chart reviewsWe have not had any issues with their reviewsI am very sorry you have issues with the billing?

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 12204204, and find that this resolution is satisfactory to me.
Sincerely,
[redacted]

I would like to apologize for how this situation was handled. [redacted] actually works with an Infusion company SETMA partners with. She is an employee of them. I will personally share with her supervisor about this complaint. SETMA's Director of Clinic Coordination will as well discuss...

the situation with [redacted] and let her know that it is not our  practice to discuss situations with patients in the waiting area. [redacted] will be made aware of how to appropriately deal with patients. I am aware that we have had difficulty with her insurance company and the infusion center making sure there was proper authorization to proceed so I can understand frustration on the patient as well as the infusion staff as they have been trying hard to get this taken care of.

Just left LumbertonSETMA ofc and was treated like a bag of bones. The Dr. acted like I was an inconvenience and not one looked in my face and asked if I had a problem that needed to be checked. Contacted my insurance and was told every dr. In Lumberton was setma. Monopoly is against the law,period. I was not offered upper lower GI, bone scan and they wanted labs that I had e wks ago. Those should be taken care of with referral. Then the Dr. Couldn't look away from the computer to look me in the face. He then informed me that I was on too many addictive drugs. Did I do that? I have to have tests because of that and with DX of PTSD this Dr has the nerve to be offended! I was offended. No exam or nothing! I must have been at VA or maybe this doc is there only for $$$$ and not care for patients.

Complaint: 12032718
I am rejecting this response because:
Sincerely,
Richard Coward  Is it usual business practice to charge for both an outpatient office visit and a wellness visit at the same time?  Their response to me sounded like a politician talking in circles and saying nothing.  Their charge for the pneumonia shot was nearly $200 more than what is charged in other places.  They give me a shot and also charge me for giving me the shot.  The nurse didn't take 3 minutes and they charged $55.  Lidocain is usually used for numbing the site where an injection is to be given.  I am nearly 70 years old and have never had lidoain included in an injection.  As for the doctor's code, I spoke to my doctor about the issue before I left.  I was told who was doing the coding and the charging off.  As I said in my complaint, it is not the doctor.  I have known him for many years and consider him a friend.  SETMA needs to get its act together, admit that they have messed up, and fix the problem.  Does Larry know about this?

The complaint was reviewed. A call was made to Mr. [redacted] and an apology was made to him. He was offered to see other providers within SETMA and to chose a different primary care physician that would better fit his needs. Mr. [redacted] responded positively and will be called again this week for follow up...

to see if he made his decision about another provider. The patient has a contractual agreement with insurance company to pay co pays. By regulations SETMA is obligated to collect copays for office visits when the patient are seen. As of this time we cannot provide credit on the account as the two visit involved being seen by the provider. If the patient would have left before being seen we could refund the copay. SETMA CEO has reviewed the complaint and due to confidentiality nature I am not at liberty to discuss what occurred between him and Dr [redacted] however know that this has been discussed and dealt with in an appropriate manner.Submitted by[redacted], RN MSN Director of OperationsSoutheast Texas Medical Associates, LLP

Medicare allows an annual wellness visit yearly which is NOT a physical. It looks at the preventive measures needed such as immunizations etc. for the 1/31/17 visit there was no annual wellness visit. There is a note in the chart that says the patient did not wish it to be done and it states do not...

charge. I do not see in the record where it was billed at this visit. As a matter of reference,  Medicare wellness can be done at the same time of a sick visit as it is not, as mentioned, a physical exam. Prevnar is the pneumonia vaccine that was given. There are 2 different pneumonia vaccines that are now recommended for patients to have. Prevnar is the newest and covers different strains than the regular pneumonia vaccine. Prevnar is more expensive, which is not a billing problem but a problem with the cost of pharmaceuticals. Lidocaine is given when an antibiotic is given as those injections are very painful so a bit of lidocaine is mixed with the injection to make it be more tolerable. This is common practice but we can make sure and inform patients this has been added for their comfort.  At SETMA the doctor enters any billing codes they use during the visit. The billing office just complies these and sends to the insurance company. The billing falls with the provider.

The Medicare wellness exam is relatively new and can be done yearly. Because it is not a physical exam but a review of records and preventive measures it can and often is done with a sick visit. These are the rules Medicare allows or we would not be able to bill for it at the same time. Dr [redacted] is acutely aware of this and encourages all providers to get the wellness exam done when it is appropriate for each Medicare patient and to do this early in the year if possible. Each insurance company has a contractual agreement with physicians. There are contractual charges that are adjusted off that you nor the insurance company is not responsible for paying. These are shown on the estimate of benefits statement you get from your insurance company.  That is the same with the prevnar. It is very expensive for us to purchase. We do not compare prices with other entities but come up with reasonable and customary charges and the adjustments as well which are approved by the insurance companies through the contractual agreement. Every injection has an injection fee associated with it. That is standard and allowed by the rules set by the medical board. Lidocaine mixed with an injection (not a topical rub) is often added to the  antibiotics to lessen the pain. I am sorry they did not tell you before giving you the injection. It was not done to cause you any grief with billing but to make it less painful at the injection site. Every provider enters the codes they wish charged for at the visit. The billing office only looks for visits that do not have codes attached and then they must get with the provider to see what they want. they review records to ensure there is proper documentation to support the codes used for billing. They cannot and do not make up the codes. We have people that are assigned to review charts and ensure the documentation matches the billing codes. Insurance companies also do this. They come to our site and do chart reviews. We have not had any issues with their reviews. I am very sorry you have issues with the billing.

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 10456881, and find that this resolution is satisfactory to me.
Sincerely,
[redacted]

This letter is in reference to a Revdex.com of Southeast Texas Beaumont complaint  ID 10456881 received by Southeast Texas Medical Associates on Monday March 2nd, 2015.We received a request from Ms. [redacted] on Friday, January 9th, 2015.  There are steps that we follow in order for a refund to...

be completed and it usually takes 4 to 6 weeks.  The time will vary depending upon on the date we received the over payment, pending insurance reimbursement and other balances within the account.  This refund should have been completed and received by Ms. [redacted] on Friday,  February 20th, 2015 to allow the maximum allotted time of 6 weeks.   Due to unforeseen reasons within the Accounts Payable Department they fell behind and this refund was not mailed until February 23rd, 2015.    We apologize for any inconvenience that this may have cost the patient.    Please let me know if you have any further questions or need additional information. Thank you, [redacted] C. [redacted] C. [redacted], CPCDirector of CBOBilling, Collections, Referrals & Front OfficeSoutheast Texas Medical Associates, LLP

Southeast Texas  Medical Associates LLP response to complaint 10269859
Our staff have spoken with Mr. [redacted] regarding his daughter’s test. We applied the event monitor at our office and it gets sent in for reading. He is required to pay his 10% which is $139.87. The bill is in appeal...

and he will owe nothing. Even if the appeal is denied, he will not have to pay anything. We have never had this company deny any insurance and this is the company we use for all our event monitors.
According to [redacted], Director of referral/billing department she has called him. She talked to him on 10-10-2014, he wanted to communicate via e-mail, because he had a meeting that day.
She told him that she would call him back after she found out what or who could help him.
After she checked with Dr. [redacted]’s pod and talked to [redacted],  she called him back and left him and extended message letting him know that he needed to talk to [redacted] at Dr. [redacted]’s pod.
[redacted] the nurse in Dr [redacted]’s pod who has been working the appeal with his insurance company will also call him.
 
Sincerely,
[redacted], RN MSN
Director of Operations
Southeast Texas Medical Associates, LLP