Urological Physicians of San Diego, Inc

Review: I was referred to Genesis Healthcare and Dr. [redacted] by my primary physician. When scheduling my medical procedure I specifically asked the front desk at this business to notify me if the cost of my procedure would exceed my insurance coverage and was told that I would be notified if my insurance didn't cover any portion of my procedure. "They'll call you if your insurance doesn't cover something", is roughly what I was told after asking. I wanted the opportunity to seek care elsewhere if my out of pocket cost would exceed my office visit copay. My right as a consumer allows me to price shop if I'm paying out of pocket for anything.4 weeks after my procedure I received a bill for $1212 with a $663.78 'Patient Balance'. When I called the billing department I was told that this is the balance that isn't covered by my insurance and wasn't offered a resolution, only told that the billing department would call the receptionist about the fact that they didn't contact me about the cost to insurance difference like I'd asked. Clearly I was not notified that my insurance didn't cover that portion of the bill before my procedure and therefore was not given the opportunity to seek care elsewhere, perhaps at a medical office that offered a better price for my insurance coverage and certainly one that wouldn't gouge a customer for an exorbitant out of pocket cost with no previous notification of it.The price of the procedure at this office looks to be twice the cost that it would be at another facility, which my insurance would have covered. The incompetence in simple patient notification is unacceptable and I feel defrauded out of $663.78.I don't think that blindly gouging a customer is an acceptable business practice, especially since I have to have a follow-up visit in a few weeks. If I refuse to pay the bill for what I feel is fraudulent practice, sheer incompetence at best, it would affect my credit rating which I've kept clean by fulfilling my obligations as a consumer and paying my bills on time.Desired Settlement: I was not notified of an out of pocket cost so I shouldn't be charged an out of pocket cost. It's ridiculous to expect that after a customer explicitly requests prior notification about out of pocket costs. Incompetence doesn't reimburse a $663.78 out of pocket cost for my if I were to pay it. The billing office should accept the amount that my insurance paid them as paid in full for this account and adjust my Patient Balance to $0.

Business

Response:

We are in receipt of a Revdex.com Complaint dated 6/18/2015 where the patient relays concernsthat they were not given opportunity to price compare the cost of services and were givenwrong information regarding their coverage. The physician office did verify coverage andbenefits with the patients insurance plan and unfortunately was told wrong information bythe plan. This wrong information from the health plan was relied upon by both the patientand the medical practice.The physician is a contracted provider with the patient's insurance plan and has acceptedthe contracted rate. We are entirely sympathetic to the patients concern for pricetransparency and we endeavor to provide that to all our patients as we know that theyhave a choice when selecting physician services. Unfortunately the goal of getting accuratebenefit information up front was not met in this situation. But to assure the fairness of theprice being charged to the patient we have reviewed Health care Blue Book, an independentpricing service available to consumers to determine if our contracted rate with theinsurance company is a fair price. The price we are charging is over $100 less than theHealthcare Blue Book fair price amount. So while the goal offull transparency was not metin this instance, the prices being charged are more favorable than Healthcare Blue Bookpricing based on the patient's residential zip code. The physician is not price gouging asthe rates being charged are those established by contract with the patients insurance andthose rates do compare favorable to independent market analysis.The patient's insurance company offers online access to its members as well as customerservice phone representatives fully available to the patient for independent price andbenefit comparisons. The patient is ultimately the purchaser of their insurance contractand responsible for knowing it's provisions. The patient has signed a financial agreementwith the practice whereby they agree to pay any copayments, deductibles or coinsuranceamounts. Genesis Healthcare Partners does its best as a courtesy to patients to verify thecoverage and benefits prior to services and communicate patient responsible amounts; butwe are not the financial guarantor of how each insurance company will process a claim.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

When shopping for any service, a consumer will look for the best price. Genesis Healthcare maintains that their price for service is nearly $100 less than Healthcare Blue Book's Fair Price Fee when it is in fact NOT a lower price, but 155.99% higher. The bill I received for service was for a total of $1212, minus the amount that my insurance company covered which left a remainder of around $693, the disputed amount which is why I firmly believe that this business is price gouging its patients. I'm certain anyone would agree that $1212 is quite a bit more expensive than a $777 Fair Price Fee, especially when you don't get a bill (and a surprise at that) until 4 weeks after your procedure.