It is no secret that we live in a world where the complexities of the insurance billing process leaves upon the door for fraud to run amok. Let me give you a personal example of just one such instance.
In August of last year, my wife was seen by an emergency room physician who was a member of larger group that was contracted with her insurance company, Aetna, but they were not contracted to accept Aetna's HMO. However, given the fact that it was emergency care, my wife's out-of-network benefits dictated that the group must accept her and send them the bill. Without fail, the bill was submitted to Aetna within 72 hours for which they received payment in the amount of $413.12. Upon receiving this payment, the billing company for this ER group, changed the original procedure code and re-billed Aetna using the new procedure code. (Now, unless you bill a corrected claim to Aetna using their central fax number,
you cannot bill corrected claims to Aetna. They are not set-up to accept corrected claims into their automated electronic adjudication system used to process normal claims. ) After receiving two denials for my wife's "corrected" claim, they then billed her for the difference in charge between the new procedure code, $605.22, and what they were paid for the original procedure code, $413.12,a total sum of $192.10!
My wife, being the diligent and honest woman she is, paid the bill and then handed it to me to file away. Upon reviewing it I noticed that she was being balance billed, a practice that is not necessarily illegal. I decided to listen to my "sixth sense", as she would call it, and look at her EOB to make sure the charges were legitimate. Sure enough, the EOB clearly stated that she was, under no circumstance, to be balance billed for this procedure! So I promptly called them and demanded a refund. After being on hold for quite some time, I was finally allowed to speak to a nice young girl who informed me that a mistake had been made and that a refund would be processed promptly. She told me that my wife could expect to see the refund posted to her account within 30 days.
31 days later, the refund had still not been received. Another phone call to the billing company and another hour long wait turned up another representative who
refused to let me speak to a supervisor but informed me that the refund had in-fact been processed and that it was pending a deposit to my wife's bank account. After getting off the phone with the billing company my wife decided to call her bank and follow up on the supposed deposit. Surprise, surprise: a refund was not pending, AT ALL!
At this point my wife decided to try and get her bank involved. She opened an investigation, and the bank did its due-diligence and tried to resolve the matter with the billing company. After another 30 days, she was informed by the bank that there was nothing they could do to help.
So now, just a couple of days before this writing took place, we were back at square 1. I decided to get involved again and sure enough, after another
hour-long-wait, I was allowed to speak to Benjamin R. Oh Benjie, poor Benjie, he didn't know what he was running into when he started spewing off at the mouth to me that day! You see, Benjamin told me, again, that no supervisor could speak to me. He informed me further, that not only was my wife's refund not processed but that
AETNA HAD REQUESTED A REFUND OF THE ORIGINAL PAID AMOUNT OF $413.12 AND NOW MY WIFE WOULD BE RESPONSIBLE TO PAY THAT BALANCE! This is where I went into "thermo-nuclear" mode against the billing company.
I promptly hung up with Benjamin R. and called Aetna's member services. I detailed the events to aetna and sent them copies of everything, it was then that they discovered the billing company had tried to double bill Aetna for the emergency procedure and billed my wife instead when they had recorded 2 denials of the claim. Aetna took it upon themselves to call the billing company at this point and then conferenced me into the conversation at which time we were told, " A refund has been processed to your wife's account but it can take up to 90 days for it complete"!
One word was my reply to them, "
Unacceptable"!
Promptly, I filed a complaint with Aetna's Fraud unit, the FTC and the Better Business Bureau. I then sent a copy of the complaints to the owner of Physicians group in hope that he would see who he is allowing to represent him and that he would do something about it.
There is a recurring theme above. If you, as a medical practitioner, have a billing agency, staff-member, department or other entity in your employ, the words "
unacceptable, hour-long-wait, it's the insurance company's fault, refused to let me speak to a manager, and fraud" had better never be used in the same sentence with them...
EVER!!! These people represent your business, YOUR LIVELIHOOD on a daily basis, THEY REPRESENT YOU! These are the people you trust to provide CUSTOMER SERVICE to your patients and like it or not your patients are YOUR CUSTOMERS and without your customers, you have no practice.
What does this all mean? Choose your billing company or billing personnel wisely! If you outsource, stay on top of them, audit them from time to time or enter a fake person with your address into your management system and have them send you a bill and see how they handle the situation when you call in; do whatever you have to do to make sure that your name and your practice are being represented fairly. Trust me, even though the FTC and BBB don't do anything about a claim 99% of the time, the complaint gets logged in a searchable online database that patients, potential patients AND INSURANCE COMPANIES all check on a regular basis. The database may not cause you to loose many patients but if one of your top insurance payers decides to check up on you and sees one of those complaints,
kiss your contract with them goodbye.
We live in the digital age and word of mouth is everything. Make sure the words being used to represent you are the right ones.
opticXpress is a reputable optometric billing company. We treat everyone fairly and we always make sure that your practice is represented in the best possible manner!
Contact us today.
