Sun Life Family Health Center

I have reviewed Mr. [redacted] account and the details of his visit on December 1, 2016. Mr. [redacted] appointment was scheduled on November 23, 2016 for a visit date of December 1, 2016. I do not see any history of the appointment being scheduled with a doctor and moved to our Physician...

Assistant. Mr. [redacted] originally scheduled the appointment as a new patient visit. When Mr. [redacted] presented at the appointment 8 days later he told the provider that he had been experiencing foot pain for the past 4 days. The provider determined that Mr. [redacted] had swelling and pain in his ankle. In an effort to ensure that Mr. [redacted] did not exacerbate his ankle injury the provider choose to treat the injury by ordering x-rays and immobilizing the ankle with a boot. At the time, Mr. [redacted] had private insurance with [redacted] Health and [redacted] Insurance. Based on Mr. [redacted] contract with his insurance company he has an individual deductible of $1,500 and coinsurance of 20% after the deductible is met for any durable medical equipment, which would include the surgical boot that was placed on December 1, 2016. It is not the policy or practice of Sun Life providers to know or be expected to know the various types of insurance coverage for every individual that the provider may treat on a daily basis. In most cases Sun [redacted] would not know if a patient has met their deductible until the claim has been submitted to the patient’s insurance company. Sun Life apologizes for any misunderstanding that may have occurred around the placement of the surgical boot for Mr. [redacted]. Unfortunately, per Mr. [redacted] insurance the $12.85 was applied to his annual deductible and Sun [redacted] is responsible for collecting the funds from Mr. [redacted]. If Mr. [redacted] would like a copy of his explanation of benefits from his insurance company, [redacted], we would be more than happy to provide that documentation to him.

The organization did not make any effort to rectify the situation. I was told over the phone when I made the appointment I would be seeing a doctor, not a PA. The scheduling representative was then clearly misleading as they did not differentiate doctors from PA's. There was no medical necessity for a surgical "post op" shoe as stated on the EOB. The PA stated that I need a full boot, however they did not have the equipment on site. There was no attempt or offer to order the correct medical equipment for my injury, and after a follow up appointment elsewhere I was told that there was no medical necessity for the surgical shoe as it had nothing to do with my injury. The PA, therefore, is behaving as a salesman telling patients that they need DME that is not medically necessary. Again, after multiple attempts to contact the office there was no reply. The provider is taking no responsibility for rendering frivolous care/DME to me.