ComplaintsforA Place for Women, P.A.

• Initial Complaint

  12/01/2022

  Complaint Type:

  Product Issues

  Status:

  Resolved

  More info

  Date of transaction 6/1/2022 Amount paid $842.00 ********* services The payment made was a prepayment based on an insurance quote on the amount I would be expected to pay in total for services throughout pregnancy and including delivery. If a prepayment was not payed, the practice stated they would refuse to treat/see the patient. Since making this prepayment, my insurance policy reach its Max Out of Pocket. I asked the billing department of the practice to re-quote the services with my insurance company and refund the difference. They refused to comply with this request. They stated they would submit the claim upon the delivery of the baby, and once the claim was completed and insurance paid their portion, they would either bill or refund me the difference. They estimated this to take **** business days in total from the time the baby was born until a refund is issued (if there was one). The baby was born 11/22/2022, and the claim has still yet to be submitted to insurance.I want the practice to issue a refund of my prepayment. Due to reaching max out of pocket prior to their claim submission, the amount I owe will be $0.00 since the practice is in network and all services are covered. The billing department has also not submitted the claim promptly as they said they would, leading to my refund being further delayed.

  Business response

  12/29/2022

  December 28, 2022
  
  
  RE: Complaint # ********
  
  Please see below timeline of patient services:
  
  
  5/24/2022
  Eligibility and Benefits Inquiry was completed for obstetrical services.
  Benefits highlighted below:
  Deductible $500.00
  Out of Pocket $2,000.00
  Coinsurance 20% after $500 deductible met
  
  5/24/2022
  Called patient to review her maternity benefits and provide good faith estimate based on above eligibility from her health plan coverage Aetna.  
  Advised the patient benefits and eligibility does not a guaranteed payment and that the amounts provided were estimates until the claim is remitted. Also advised patient once we submit the claim to her insurance after delivery, if there is any outstanding balance due from patient, she would receive a bill or if there is an overpayment, she would receive a refund.  Patient agreed understood.
  Patient responsibility:
  20% coinsurance for ante-partum and delivery with insurance allowable of $4,212
  20% of $4,212 = $842.40 total estimated patient responsibility due by 20th week of pregnancy.
  The patient agreed and advised she would remit her patient responsibility at next office appointment.
  
  6/1/2022
  Patient came for her appointment and paid the estimated patient responsibility of $842.00 
  
  11/22/2022  
  Patient ********* ******* closed) 
  11/23/2022 11/25/2022 Office closed due to Thanksgiving Holiday.
  
  11/28/2022
  The patients husband called to advise that his spouse (our patient) delivered and that the practice owed him a refund of the $842.00 that the patient paid since they had met their deductible. I advised the spouse that once we submit the claim to the insurance and the claim is paid, if there are any funds/overpayments due to the patient, it would be remitted. I did advise the spouse that due to the holiday the claim has not been submitted yet and by Aetna policy, the provider has 180 days from date of service to submit the claim. I did, however, advise him that once I receive the hospital delivery notes, I will submit the claim.  
  Timely Filing limit to Aetna
  Aetna requires providers to submit claims within 180 days of the date of service unless otherwise specified within the provider contract.
  
  Ones the claim is submitted electronically and received by the insurance payor; it can take ***** business days to receive payment from insurance.  
  
  12/5/2022 Patients husband called back questioning why we have not submitted the claim to his insurance for his wifes delivery. The practice advised him that the claim was submitted earlier in the morning. He then told the office staff that he will be calling back every day until we process a refund. Unfortunately, there is no telling if a refund is due at this time as we have yet to receive an explanation of benefits from the insurance payor on patient responsibility.
  12/13/2022 Patients husband called back to check on the status. Advised him that I would call to obtain an update, however, the insurance payor has ***** business days to remit payment.
  12/19/2022 Patients husband called to obtain an update. Advised we have not received payment to date.  He advised on his end he was able to retrieve from the web site that a payment of $4,380.00 was sent to the practice. Our processing time to receive payments from the date received to the date it reflects in our system could take **** business days as checks are mailed in bulk to our corporate office and then posted individually to each patient account. (Payors remit patient payments in 1 lump check not individually by patient which creates a processing timeframe).
  12/20/2022 Aetna rep called the office to notify that a payment has been processed but in a bulk payment. The rep advised that she would call the spouse to notify.  
  12/20/2022 Received a call from BBB *****, said that ***** patients husband opened a case and they sent an email and has been waiting for a response. The email was **************************. I advised her that she had the wrong email and provided her the correct email address.
  In closing, since the patient met her deductible and out of pocket maximum during her pregnancy, she is covered at 100% versus the estimated 80% when benefits were verified. As mentioned to the patient ince we receive from the insurance her explanation of benefits if there is a balance due or refund, it will be processed once received from the payor directly.However, the patient and the patients spouse are requesting we deviate from insurance and practice policies and not follow processes. It has been less than ***** business days since the patient has delivered and the patient nor the spouse has allotted the proper timeframe for the insurance and the practice to receive, process, and post payments accordingly. To date, we have been able to confirm a payment was submitted to the practice in the amount of $4,380.00 as part of a bulk payment of $444,835.74 under EFT/Check#*************** dated 12/21/2022.
  The bulk check was processed 12/27/2022, which means the payment will be issued as an EFT deposit on Aetnas check run date. Although the claim shows as paid on the payor side, our system has to post under each patient individually and deposit into the corresponding care center from corporate.Once its deposited into FWC US Bank account, then it creates a deposit batch & payment batch for posting of the payment which likely will not be until next week. Once posted to the patient account, I will be able to proceed a refund if a refund is due which according to the explanation of benefits, a refund is due. However, the system will not allow me to issue a refund until the payment is posted on the patients account.
  If you have any further questions or concerns, please do not hesitate to reach out to me directly.
  
  Sincerely,
  
  *****************************
  
  ***********************************************************

  Customer response

  12/29/2022

   
  Complaint: 18487770
  
  I am rejecting this response because:
  

  although there appears to be policies and processes in place, the business failed to present and inform the patient or myself of these policies. This lack of communication has led to the issues regarding the refund of the prepayment. We were informed that the prepayment would be refunded if we are to be responsible for less. Following this, an administrative representative at the front desk of the practice confirmed that they would refund us if we owed less. We brought to the attention of the billing department of our max out of pocket status well before delivery and provided proof that our financial responsibility would be zero for the claim that was yet to be submitted. We did so in an attempt to begin the refund of our prepayment in advance. Only at this time were we told we would have to wait for the delivery date for the claim to be submitted and paid in order for a refund to be submitted. At no point were we informed of how long it would take or a timeframe to process the refund after the delivery date.

  Sincerely,
  
  ***********************

  Business response

  01/17/2023

  As referenced in previous letter dated 12/28/2022 (attached)on 11/28/2022, we notified the patients husband upon receipt of EOB and insurance payment. Any amount due to patient would be processed.
  Insurance payment posted 12/28/2022
  Patient refund processed - 1/6/2023
  Attached maternity benefits were provided to patient at first OB appointment.
  This refund has been remediated. If the patient has additional questions, the patient is encouraged to contact their insurance company.
  

   

  Customer response

  01/17/2023

   
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. Ive received my refund. Too bad it took 45 days from the treatment date to receive it. Business should apply a disclaimer to all future prepayment notices that refunds could be delayed and provide an explanation.

  Sincerely,
  
  ***********************

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