ComplaintsforAlternative Risk Management

• Initial Complaint

  06/02/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  After breaking my arm in December 2021, I contacted my health insurance company to make sure the orthopedic facility I visited was inside my network. I was informed that "**** ******** Ctr For Orthopa" was in my network. The facility confirmed that they accepted my insurance and treatment was administered. Afterward, I received an Explanation of Benefits from Alternative Risk Management stating that the entirety of the **** was the "Patient's Responsibility" and nothing would be covered by my insurance provider. I was able to speak with ***** at Alternative Risk Management (my insurance provider) and she informed me that I was in fact covered but they were "waiting for advisal to release the checks" and "the claims have been processed". I was instructed to call back in two weeks. This process of calling ***** continued every few weeks from January through present. On one occasion, they informed me that I had to mail them a form describing the nature and location of my injury so they could decide whether it was my own fault or a third party's fault and this was the reason for the delay. During my latest conversation with ***** I was told that my claim is being audited by an outside agency. Meanwhile, the health care provider has sent my **** to a collection agency which will be reported, negatively affecting my credit if not settled before July 1. I simply want Alternative Risk Management to do what they promised when I purchased their insurance plan, process my claim and pay their portion of my ****.

  Business response

  06/15/2022

  Customer: ***********************************
  ******************** ID # ********
  Provider: **** Virginia Ctr for Orthpaedics
  
  
  11/11/21 - RECEIVED A CALL FROM THE MEMBER REQUESTING A COPY OF HIS ID CARD AND A *** DIRECTORY FOR AN ORTHOPAEDIC DOCTOR BECAUSE MEMBER VERBALLY STATED HE BROKE HIS ARM.
  A *** DIRECTORY AND ID CARD COPY WAS EMAILED 11/11/21, PER MEMBER REQUEST.
  
  11/12/21 - INITIAL ACCIDENT LETTER MAILED TO THE MEMBERS RESIDENCE.
  
  11/29/21 - ORIGINAL CLAIMS RECEIVED FOR DOS 11/11/21 & 12/15/21, PROVIDER DETERMINED TO BE OUT OF NETWORK BY PHCS. THE HEALTH PLAN ONLY ALLOWS FOR IN-NETWORK PROVIDERS. 
  TO DATE, NO DOCUMENTED RESPONSE RECEIVED FROM MEMBER WITH ACCIDENT DETAILS.
  
  12/3/21 - CLAIM WAS CLOSED/DENIED AS OUT OF NETWORK PROVIDER NOT COVERED.
  TO DATE, NO DOCUMENTED RESPONSE RECEIVED FROM MEMBER WITH ACCIDENT DETAILS.
  
  03/30/22 - THE MEMBER CALLED THE PROVIDER AND HE WAS TOLD THAT THE PROVIDER WAS CONTRACTED.  ARM CONTACTED PHCS TO REPORT THE *** DISCREPANCY, SERVICE CASE #*******.
  TO DATE, NO DOCUMENTED RESPONSE RECEIVED FROM MEMBER WITH ACCIDENT DETAILS.
  
  4/8/22 RECEIVED PHCS RESPONSE TO SERVICE CASE #*******, PROVIDER IS CONTRACTED AS IN-NETWORK.
  TO DATE, NO DOCUMENTED RESPONSE RECEIVED FROM MEMBER WITH ACCIDENT DETAILS.
  
  4/8/22 - SECOND ACCIDENT LETTER WAS EMAILED AND MAILED TO THE MEMBER DUE TO NO PREVIOUS RESPONSE. 
  
  05/19/22 RECEIVED THE SIGNED ACCIDENT LETTER FROM MEMBER VIA ***** CLAIM WAS RECONSIDERED.
  
  6/2/22 AM ARM RECEIVED A CALL FROM MEMBER INDICATING HE RECEIVED A COLLECTION AGENCY LETTER INFORMING HIM THAT IF THE CLAIM WAS NOT PAID BY 7/1/22 IT WOULD BE ON THIS CREDIT REPORT.
  
  6/2/22 PM CHECK PRODUCED AND MAILED TO PROVIDER.  CORRESPONDING EOBS EMAILED TO MEMBER.
  
  
  *************************
  Sr. Benefits Administrator
  ARM LTD 
  814 ******************
  *****************, ** 60004
  ************

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