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Summit Eye Consultants, PLLC

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Summit Eye Consultants, PLLC Reviews (1)

May 1, 2017     Revdex.com PO Box 1000 Dupont, WA 98327     RE:  COMPLAINT# [redacted]     I received your letter dated 4/18/17 regarding this complaint on 4/28/17 in the mail, and have taken some time to perform an investigation into this...

matter.  My response is as follows:   It is unfortunate that this patient has chosen to blame her eye care provider for decisions that are controlled solely by her insurance carrier.  Only her insurance carrier has the ability to determine whether an office visit will be labelled as a routine eye visit or a medical eye visit.  As a contracted provider for her insurance carrier, Tricare, we are obligated by contractual agreement to provide the diagnoses that are relevant and appropriate for a patient’s claim.  Although the diagnoses are individualized for each patient depending on the findings on exam, the exam code that is sent to Tricare for the office visit is the same whether it will then be processed by Tricare as a routine eye exam or a medical eye exam.  Based on this process, the eye care provider does not have any role in the determination of a patient’s eye exam to be routine or medical.  It is strictly a Tricare decision, one that Tricare bases on the individualized set of diagnoses that is sent in with the eye exam claim.  It must be emphasized that the unique list of diagnoses assigned to the eye exam claim is based solely on the unique findings that are discovered for that particular patient on eye exam.  As a result, there is no way to know ahead of time whether the unique diagnoses list of a patient will generate a decision by Tricare to process the claim as a routine eye exam or a medical eye exam.  As you can see, it is obvious that the eye care provider has no role in the decision-making process of the insurance carrier which ultimately determines whether an eye exam is considered routine or medical, other than to truthfully report their findings as a unique diagnoses list for the patient.    My staff worked diligently with this patient to ensure that she had complete understanding of her situation with her insurance carrier prior to, during, and after her appointment.  Upon calling to make the appointment the first time, she was told of the difference between a routine eye exam and a medical eye exam, and that her insurance would only cover a routine eye exam without preauthorization.  My office manager told her we were hesitant to schedule her appointment because of the high chance that she would be a medical eye exam based on her age.  Patient proceeded to schedule the exam for 10/28/16.  She moved the appointment twice thereafter, and finally showed up to her appointment on 11/4/16.  After her insurance carrier was billed and subsequently denied coverage for the eye exam visit as it was labelled by Tricare as a medical exam based on her unique list of diagnoses, financial responsibility shifted to the patient.  The patient had already acknowledged her financial responsibility should her carrier not cover for her eye exam visit at the time of the visit when she signed our financial responsibility form.  She was sent a statement on 12/12/16.  After 2 months of non-payment, the patient was contacted by our office manager.  The patient informed my manager that she was going to work on getting a referral retro-actively with her primary care physi8cian.  After another month, the patient was contacted again 3 more times by telephone.  There was no response to the 3 voicemails, or to the collections warning letters we sent subsequent to the voicemails.  Per office protocol, the patient was then sent to collections.    To avoid this situation in the future, my office will no longer accept Tricare Prime patients without a preauthorization on hand.      Respectfully,     Jacqueline W[redacted] MD

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Address: 945 Hildebrand Ln NE Ste 235, Bainbridge Is, Washington, United States, 98110-2877

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