Southwestern Ear, Nose & Throat Associates

We do not have any services that are no cost Every person that answers the phone has been employed here for many years and knows that each patients’ benefits may vary and explain by script that they can give a range for a service, but until it is coded by the provider the charges may vary and responsibility is affected by the deductible you have already met Every patient makes a decision whether to have services or not Mrs [redacted] states that she knew the baby was fine, but decided to keep the appointment after a newborn screening at the hospital had already shown the baby had passed Benefits were not pulled on this patient prior to the visit, so anyone answering the phone would not have been able to determine there would be no cost to herMrs [redacted] states in the complaint that she has no issues with the services rendered, but does not want to pay for the services she received She states numerous times she knew there was no issue with the infants hearing, but came to the appointment regardlessI spoke to Mrs [redacted] this morning She stated that as a new parent she was frazzled and nervous regarding her infant’s hearing She expressed anger at taking off work and coming to an appointment that was stressful for her daughter even though she knew she was fineThe audiologist that completed the test recalled Mrs [redacted] saying that she had spoken to the pediatrician who suggested she still come to ease her mind When I mentioned this to her during our talk, she said that it was our office she calledWhen I pull the records to see who she has spoken to, her appointment was made by a supervisor and follow up call prior to the appointment was transferred to a supervisor as well Even when insurance benefits are pulled and estimated in our office, it is extremely difficult to know what other services a patient has had recently which may affect what is covered She may have been told it was a covered service on her plan and in her nervousness with a newborn misunderstood, but would not have been told there was definitely no costIt could have been offered that we bill her insurance and then bill her rather than make her pay on the date of service and then having to refund her if her deductible had already been met Many services are covered, but may be disallowed if a deductible has not been met I have attached the eligibility pulled on this patient It states coverage, but does not state how much of the deductible has been met Patients are always told to call their insurance company if they are unsure and want a closer estimate The benefits pulled even state “accumulated amounts such as deductible may change as additional claims are processed.” When the mother arrived to the appointment, she signed our financial policy stating she understood services or charges not covered by insurance would be her responsibility I have attached that When speaking today, she said that she just wanted to meet in the middle regarding the $charge The actual charge was $but as per her insurance contract, we discounted the service to the allowable rate of $ Her insurance company believes that she paid us $for the service and will use that number in calculating other services and where she is on meeting her deductible Not paying for the service results in our practice committing fraud to her insurance company I have attached the statement showing this reduction We provided services in good faith expecting payment from insurance or Mrs*** Mrs [redacted] states in her complaint that she is disputing the amount, but the services were rendered by our staff and supplies were used for what she believes should be provided for free

We do not have any services that are no cost.  Every person that answers the phone has been employed here for many years and knows that each patients’ benefits may vary and explain by script that they can give a range for a service, but until it is coded by the provider the charges may vary and...

responsibility is affected by the deductible you have already met.  Every patient makes a decision whether to have services or not.  Mrs. [redacted] states that she knew the baby was fine, but decided to keep the appointment after a newborn screening at the hospital had already shown the baby had passed.  Benefits were not pulled on this patient prior to the visit, so anyone answering the phone would not have been able to determine there would be no cost to her. Mrs. [redacted] states in the complaint that she has no issues with the services rendered, but does not want to pay for the services she received.  She states numerous times she knew there was no issue with the infants hearing, but came to the appointment regardless. I spoke to Mrs. [redacted] this morning.  She stated that as a new parent she was frazzled and nervous regarding her infant’s hearing.  She expressed anger at taking off work and coming to an appointment that was stressful for her daughter even though she knew she was fine. The audiologist that completed the test recalled Mrs. [redacted] saying that she had spoken to the pediatrician who suggested she still come to ease her mind.  When I mentioned this to her during our talk, she said that it was our office she called. When I pull the records to see who she has spoken to, her appointment was made by a supervisor and follow up call prior to the appointment was transferred to a supervisor as well.  Even when insurance benefits are pulled and estimated in our office, it is extremely difficult to know what other services a patient has had recently which may affect what is covered.  She may have been told it was a covered service on her plan and in her nervousness with a newborn misunderstood, but would not have been told there was definitely no cost. It could have been offered that we bill her insurance and then bill her rather than make her pay on the date of service and then having to refund her if her deductible had already been met.  Many services are covered, but may be disallowed if a deductible has not been met.  I have attached the eligibility pulled on this patient.  It states coverage, but does not state how much of the deductible has been met.  Patients are always told to call their insurance company if they are unsure and want a closer estimate.  The benefits pulled even state “accumulated amounts such as deductible may change as additional claims are processed.”  When the mother arrived to the appointment, she signed our financial policy stating she understood services or charges not covered by insurance would be her responsibility.  I have attached that.  When speaking today, she said that she just wanted to meet in the middle regarding the $100.46 charge.  The actual charge was $175 but as per her insurance contract, we discounted the service to the allowable rate of $100.46.  Her insurance company believes that she paid us $100.46 for the service and will use that number in calculating other services and where she is on meeting her deductible.  Not paying for the service results in our practice committing fraud to her insurance company.  I have attached the statement showing this reduction.  We provided services in good faith expecting payment from insurance or Mrs. [redacted].  Mrs. [redacted] states in her complaint that she is disputing the amount, but the services were rendered by our staff and supplies were used for what she believes should be provided for free.