SSM Health DePaul Hospital

The patient stated he received incorrect billing information from an SSM Physician which resulted in his incurring a patient liability of $He is requesting a reduction of his liability to $139.00The physician named in the concern is an SSM PhysicianAs a courtesy in this instance a onetime adjustment of $has been posted to the hospital account leaving a balance of $This was the desired resolution stated by the patient in the Revdex.com ComplaintProvider based billing, also known as Hospital Outpatient Billing is a billing model in which a patient may receive two separate charges – one represents the facility, or hospital charge, and one represents the professional or physicians feeOutpatient services will process with insurance according the members benefitsSSM does have a Price Transparency Department that will provide an estimated liability to patients prior to service providedThe contact number for the Price Transparency Team is [redacted] A letter explaining the above, and an adjusted detailed statement are being mailed to the patient

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to meThank you Revdex.com!!! I don't think this would have ended with such a good outcome without you Sincerely, [redacted]

This complaint was originally received in this office on 6/9/- OFI # ***A letter of response was mailed to the patient on June 20, Attached is the letter mailed to the patient in response to his complaint filed on 6/9/The patient stated a call was placed to [redacted] by [redacted] at Outpatient Behavioral Med on 9/29/- call reference # [redacted] in case SSM would like to call for verification of the information providedA call was placed to [redacted] at [redacted] on 8/1/- [redacted] rep [redacted] - call reference # [redacted] [redacted] was asked to review the call between [redacted] and their rep [redacted] on 9/29/He stated [redacted] called to check the need for authorization for the CPT code *** [redacted] was informed there is no authorization needed for this CPT codeThere is no documentation that [redacted] requested in/out of network information, or that [redacted] offed this informationThere is no documentation that an out of pocket cost was requested by [redacted] or provided by ***Checking in and out of network benefits is out of scope for an authorization requestAlso, benefits vary from patient to patient, so there is no way the outpatient behavioral staff would know if a patient has coverage for a particular serviceTheir standard procedure is to refer the patient to contact their insurance and verify this information for themselves.Contact was made with *** - Team Lead Behavioral OP ( [redacted] 's direct supervisor), she stated they are instructed to refer patients to their insurance company with questions that relate to benefits, because they are not trained regarding coverage or benefitsShe also stated [redacted] is a seasoned member of her team and that she would instruct a patient to contact the insurance regarding benefitsUltimately it is the responsibility of the patient to know which providers are in and out of network with their benefitsThe patient did sign the Conditions of Admission form dated 10/5/which states the patient agrees to pay for the care received at this facility as ordered by physician(s)SSM provided a service to the patient, and he agreed to pay us the amount applied as patient responsibility according to his insurance and benefitsTwo adjustment were applied to the account to assist the patient in meeting his financial obligationFour statements have been sent to the patient, with no payment plan or other arraignment made for the balanceThe account was sent to an outside collection agency on 7/24/in accordance with our billing policy and proceduresThe collection agency will attempt to collect on the debt for days before this affects his credit in the form of negative reportingIf the patient is willing to set up either a payment plan or the Commerce Bank Health Services Financing line of credit by 8/15/SSM will return the account from collections to accommodate one of these optionsAfter that date he will have to communicate directly with [redacted] Inc (outside collections)Date-TimeNameOld ValueNew Value Date-TimeNameOld ValueNew Value

Dear Sir or Madam, A thorough review of this account has been completedWhen billing a claim for services provided at a facility (hospital emergency room, urgent care, etc.), there are several codes that need to be appliedOne is the Revenue CodeRevenue codes tell insurance companies the type of
services patients received, the types of supplies used and the department in which services were renderedInsurance companies use these codes to determine which procedures will be covered by insurance, and at what benefit level according to the members policyThe revenue code that indicates the service was provided at an Urgent Care facility is Rev Code This is a standard code used by any facility billing an Urgent care claimHospital Emergency Department claims are billed under revenue code On 1/3/a claim was billed to the patients insurance, ***The revenue code billed was 456, which indicates an Urgent Care location*** processed the claim and applied $as deductible and $as copayMs*** paid $at time of service (her Urgent Care copay amount) which left a patient liability of $The facility is required by contract to bill the patient the amount indicated as patient liability on the remittance - also called an Explanation of BenefitsOn 5/24/17, a call was placed to *** at ***, call reference number ***The representative who assisted on this call, ***, reviewed the claim billed on 1/3/She did confirm the claim was billed with the correct revenue code to indicate an Urgent Care service, and indicated she would send the claim for reconsiderationShe also verified the member has a $copay for an Urgent Care encounterShe asked that we allow 5-business days for this claim to be reviewedIf *** continues to apply the deductible and copay as the patient liability, then the member would be advised to send in a member appeal, requesting the claim be processed according to her urgent care benefitsAt this time there are no changes that are required to correct this claimThis office will continue to monitor this claim for a final determinationThank you for allowing us to review and respond to this complaint Sincerely, *** ***SSM Health - Patient Business Services

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. Thank you Revdex.com!!!  I don't think this would have ended with such a good outcome without you.
Sincerely,
[redacted]

7/13/16 Revdex.com Complaint # [redacted] Dear Sir or Madam, The billing complaint received from the patient, Mr. [redacted], for [redacted] Hospital account # [redacted] was originally received by this office on 5/16/2016. On this date Mrs. [redacted], the spouse of Mr. [redacted] called our...

Customer Service department at [redacted] to file a formal complaint and request a review of the billing. Her concern was that the patient status was billed as Outpatient and not Inpatient, which effected the billing and ultimately the patient liability. Clinical Auditor [redacted], RN reviewed the account and medical record. The attached clinical audit addendum and closure letter was mailed to Mr. [redacted] on 5/20/16. When a patient is admitted to the hospital for services, there is a dialogue that takes place between the clinical case management staff at the hospital and the patients insurance company, to ensure the hospital stay is billed accurately so there is no denial on the claim. In this instance, [redacted] did not approve an Inpatient stay, and only approved an Outpatient stay. The hospital and physician have the option to either agree with the decision of the insurance or disagree and file an appeal. This appeal would include a peer to peer interview between [redacted]’s clinical medical director and the providing physician, where a case would be made for medical necessity for an Inpatient admit. Dr. [redacted] was the attending physician, and after reviewing, he agreed with the decision by [redacted] for an Outpatient admission – he declined the opportunity to participate in the peer to peer interview. The claim was billed to [redacted] on 1/14/16. The admit date was 12/30/15 and the discharge date was 1/1/16. Because the claim dates of service span two years – 2015 & 2016 – [redacted] processed the claim in their system as a split claim – meaning they processed the charges for all services incurred during 2015 separately from the charges incurred in 2016. This was the decision of [redacted] – [redacted] submitted the claim as one claim. A call was placed to [redacted] today – 7/13/16 - to verify the claim was processed as in network according to the members benefits. [redacted] representative [redacted], call reference # [redacted] stated the claim was split in their system for processing, and both claims processed and paid according to the members in network benefits. There were no denials on the claim. The detailed statement request was fulfilled by this office on 4/6/16 and received by [redacted] o 4/7/16. Ultimately the detailed statement was not needed to complete the processing. [redacted] applied $680.81 as patient liability as a coinsurance, which is the patients cost share amount. Mr. [redacted] has Medicare Part A as a secondary insurance. Part A will only cover an inpatient admission, and therefore cannot be billed for this hospital encounter. SSM does offer several options for repayment, including a six month payment plan and  no interest line of credit through [redacted] Banks Health Services Financial Program. Financial assistance is available to those patients who qualify. Patients should contact Customer Service at [redacted] to explore these options.   Sincerely, [redacted] Senior Patient Liaison - SSM Patient Business Services

This complaint was originally received in this office on 6/9/16 - OFI # [redacted]. A letter of response was mailed to the patient on June 20, 2016. Attached is the letter mailed to the patient in response to his complaint filed on 6/9/16. The patient stated a call was placed to [redacted] by [redacted] at...

Outpatient Behavioral Med on 9/29/15 - call reference # [redacted] in case SSM would like to call for verification of the information provided. A call was placed to [redacted] at [redacted] on 8/1/16 - [redacted] rep [redacted] - call reference # [redacted] was asked to review the call between [redacted] and their rep [redacted] on 9/29/15. He stated [redacted] called to check the need for authorization for the CPT code [redacted] was informed there is no authorization needed for this CPT code. There is no documentation that [redacted] requested in/out of network information, or that [redacted] offed this information. There is no documentation that an out of pocket cost was requested by [redacted] or provided by [redacted]. Checking in and out of network benefits is out of scope for an authorization request. Also, benefits vary from patient to patient, so there is no way the outpatient behavioral staff would know if a patient has coverage for a particular service. Their standard procedure is to refer the patient to contact their insurance and verify this information for themselves.Contact was made with [redacted] - Team Lead Behavioral OP ([redacted]'s direct supervisor), she stated they are instructed to refer patients to their insurance company with questions that relate to benefits, because they are not trained regarding coverage or benefits. She also stated [redacted] is a seasoned member of her team and that she would instruct a patient to contact the insurance regarding benefits. Ultimately it is the responsibility of the patient to know which providers are in and out of network with their benefits. The patient did sign the Conditions of Admission form dated 10/5/15 which states the patient agrees to pay for the care received at this facility as ordered by physician(s). SSM provided a service to the patient, and he agreed to pay us the amount applied as patient responsibility according to his insurance and benefits. Two adjustment were applied to the account to assist the patient in meeting his financial obligation. Four statements have been sent to the patient, with no payment plan or other arraignment made for the balance. The account was sent to an outside collection agency on 7/24/16 in accordance with our billing policy and procedures. The collection agency will attempt to collect on the debt for 120 days before this affects his credit in the form of negative reporting. If the patient is willing to set up either a payment plan or the Commerce Bank Health Services Financing line of credit by 8/15/16 SSM will return the account from collections to accommodate one of these options. After that date he will have to communicate directly with [redacted] Inc (outside collections). Date-TimeNameOld ValueNew Value  Date-TimeNameOld ValueNew Value

The patient stated he received incorrect billing information from an SSM Physician which resulted in his incurring a patient liability of $918.20. He is requesting a reduction of his liability to $139.00The physician named in the concern is an SSM Physician. As a courtesy in this instance a onetime...

adjustment of $779.20 has been posted to the hospital account leaving a balance of $139.00. This was the desired resolution stated by the patient in the Revdex.com Complaint. Provider based billing, also known as Hospital Outpatient Billing is a billing model in which a patient may receive two separate charges – one represents the facility, or hospital charge, and one represents the professional or physicians fee. Outpatient services will process with insurance according the members benefits. SSM does have a Price Transparency Department that will provide an estimated liability to patients prior to service provided. The contact number for the Price Transparency Team is [redacted]. A letter explaining the above, and an adjusted detailed statement are being mailed to the patient.

Complaint: [redacted]
I am rejecting this response because: I have talked with my insurance company on 2/2/16 When I noticed payment was still pending for the [redacted] and they told me at this time it had been submitted but they had not sent an itemized bill.  I called and talked with supervisor Jarod and he was going to research and call me back.  On Mar. 3 the bill was still pending with insurance and I called my insurance company on that day and they stated that they were still waiting on an itemized bill. Finally it was received by my insurance company in April 2016.  I began receiving bills for the amount of $2900. (approximately) and called [redacted]  back and they apologized and said they would deduct the contractual amount and stated it would be sent to medicare.  When I called again in June they said it had been denied by Medicare.  The customer service rep at [redacted] said it had never been billed as inpatient and that they could not bill it to Medicare.  When I talked with [redacted] on June 7, she stated it was a 3 day stay and should have been billed as inpatient. I called my insurance again and they were upset and went over all the codes and again insisted it was never billed as inpatient and to call the hospital. I called Dr. [redacted]( the hospitalist) because each customer service rep told me that only the attending physician could change the code.  I spoke with Dr. [redacted] office and she was supposed to call me.  I also have a phone call left on my voice message from Dr. [redacted] office stating it was indeed inpatient.  Again I called my insurance and they insisted it was never submitted as inpatient. I talked with [redacted] and she had me on hold for over 15 minutes and then it disconnected.  I called back and talked with supervisor [redacted] and at this time she said yes it had been originally billed as inpatient  and told me that the Reference # was [redacted] and they talked with a [redacted] Z on Jan.4, 2016.  I have sincerely done all that I can humanly do and feel like I keep being sent back and fort with no results.  I was originally told by hospital it would be billed inpatient and my insurance insists that it was NEVER billed inpatient which would have saved the insurance money instead of being billed for observation hours. 
Sincerely,
[redacted]