Complaints

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• Initial Complaint

  Date:12/11/2024

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  Answered:

  The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Reason for reporting over a year later:We thought there was a billing error on the part of ********** Blue Shield but after almost a year's worth(Feb to Dec 2024) of back and forth with their Grievances and ************ we've finally determined the fault lies with the provider(Sunstars) not BCBS. We finally got word from BCBS on 12/10/24 that the claims in question were submitted as Specialist visits which we feel is in error.The issue: Our son with autism received ABA therapy from Sunstars from May to December of 2023 roughly five days a week. Sunstars submitted claims to **** that show a specialists visit which required us to have to pay an expensive copay (up to $60 to $120 a day even after deductible was met) when in reality his therapy came from a lower level therapy tech who came to our home to provide the service NOT an MD or ******************* visit.We did not know any better until we changed providers in April of 2024 and started being charged a much lesser coinsurance amount of around $12.00 a session after deductible for the exact same service.We feel Sunstars may have submitted incorrect codes in their claims to **** that gained them higher payouts subsequently costing us more.I contacted Sunstars about 6 months ago and they were very dismissive and told me they'd check into it but have yet to get back to me. The amount we feel that we overpaid is around $4000

  Customer Answer

  Date: 12/28/2024

  Hello thank you for your response ..Magical Moments and Sunstars Seem to be one and the same...Not sure why they have 2 different names ..Not sure which name to make the formal compliant against but for sake of moving forward I will state  the compliant is against Magical Moments ABA.  Thank you . I am standing by for further guidance on what I can do to help things move forward .

  Customer Answer

  Date: 12/28/2024

  I have confirmed that our son's health insurance plan for 2023 and 2024  include the exact same coverage for ABA therapy. The two plans are  for the ABA  therapy to go from a copay to coinsurance once deductible has been met. As mentioned in original complaint this did not happen under Magical Moments in 2023 yet  it did happen (as it should have) in 2024 under a new therapy provider leading one to believe that Magical Moments in 2023 mistakenly misrepresented the type of service our son received as indicated by the higher amounts we were billed

  Business Response

  Date: 12/30/2024

  I believe this is a bad faith complaint, please advise how to proceed. According to their account they serviced until December, this is false, we served them into 2024 when they switched to a different plan, please see the attachments. At the new year they switched insurance plan which affected their patient responsibility as it switched from a copay to a coinsurance. We confirmed this with both the insurance company and with the individual alleging the complaint and in our billing records below. There was never incorrect billing, all billing per **** required the supervising provider *** on box 24J on CMS form 1500 and that is exactly what they did. There is no way to bill as a specialist, the service codes for the services rendered are not "changeable" to specialist or not. The simplest explanation here is the reality of the situation. Their plan renewal changed the details of the policy thus changing their patient responsibility amount. This simple fact can be confirmed with their insurance, we informed the individual making the complaint here of this fact (its completely false that we were dismissive, we spoke to him multiple times, and, during these conversations he confirmed that his insurance policy changed) and we believe that this is a plain and simple smear campaign being conducted in sheer bad faith. I would not like to bring this into a public forum, please advise how we can end this matter. There will not be any refund, in fact, the individual who lodged the complaint has not even paid his dues for services provided. The reason his insurance company took no action and he is coming here is because there was no error in billing, everything was competed as it was supposed to be. The correct resolution here would be to call his insurance provider who would be able to confirm for you that there was a policy change at the time they switched providers which resulted in a change in patient responsibility. 

  Please see the attached breakdowns per the alleging party's insurance. in 2023 when they received a bill there was a COPAY this is a set amount per day no matter what, this was set at 60 (PR -3) per their insurance plan. When we serviced them after they got on their new plan in 2024, their Patient Responsibility was indicated as a COINSURANCE at 7.73 for the same services rendered, with the same CPT code. This change in amount due did not change when they switched provider, WE also witnessed this change and they received this updated patient responsibility payment from us directly. Alleging that the change accourred when they switched providers can be comclusively disregarded with the evidence provided. 

   

  Business Response

  Date: 01/03/2025

  I believe this is a bad faith complaint, please advise how to proceed. According to their account they serviced until December, this is false, we served them into 2024 when they switched to a different plan, please see the attachments. At the new year they switched insurance plan which affected their patient responsibility as it switched from a copay to a coinsurance. We confirmed this with both the insurance company and with the individual alleging the complaint and in our billing records below. There was never incorrect billing, all billing per **** required the supervising provider *** on box 24J on CMS form 1500 and that is exactly what they did. There is no way to bill as a specialist, the service codes for the services rendered are not "changeable" to specialist or not. The simplest explanation here is the reality of the situation. Their plan renewal changed the details of the policy thus changing their patient responsibility amount. This simple fact can be confirmed with their insurance, we informed the individual making the complaint here of this fact (its completely false that we were dismissive, we spoke to him multiple times, and, during these conversations he confirmed that his insurance policy changed) and we believe that this is a plain and simple smear campaign being conducted in sheer bad faith. I would not like to bring this into a public forum, please advise how we can end this matter. There will not be any refund, in fact, the individual who lodged the complaint has not even paid his dues for services provided. The reason his insurance company took no action and he is coming here is because there was no error in billing, everything was competed as it was supposed to be. The correct resolution here would be to call his insurance provider who would be able to confirm for you that there was a policy change at the time they switched providers which resulted in a change in patient responsibility. 

  Please see the attached breakdowns per the alleging party's insurance. in 2023 when they received a bill there was a COPAY this is a set amount per day no matter what, this was set at 60 (PR -3) per their insurance plan. When we serviced them after they got on their new plan in 2024, their Patient Responsibility was indicated as a COINSURANCE at 7.73 for the same services rendered, with the same CPT code. This change in amount due did not change when they switched provider, WE also witnessed this change and they received this updated patient responsibility payment from us directly. Alleging that the change accourred when they switched providers can be comclusively disregarded with the evidence provided. 

   

  Customer Answer

  Date: 01/14/2025

  Hi I have been out of town with holiday travel and missed this ...

  Can you please not close case and allow more time for me to respond to the business?

  Customer Answer

  Date: 01/23/2025

  Thank you for reopening,

  I have been preparing my response and hope to send tonight or first thing in the morning(1/24)

  *******

  Customer Answer

  Date: 01/24/2025

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined the response would not resolve my complaint.  For your reference, details of the offer I reviewed appear below. 
  
  [Provide details of why you are not satisfied with this resolution.]

   

  I have confirmed multiple times that Teddys plan in 2023 2024 and now in 2025 is the exact same regarding how his ABA Therapy is covered.  In Speaking with a BCBS representative I was told that the charges from 2023 did not make sense to her either.  This representative recommended that I file a grievance against Magical Moments.
  
  
  
  
  
  
  I believe this is a bad faith complaint, please advise how to proceed. According to their account they serviced until December, this is false, we served them into 2024 when they switched to a different plan, please see the attachments.
  YES IT IS TRUE THAT WE SERVICED WITH MAGICAL MOMENTS INTO THE NEW YEAR (2024) AND DID SEE A CHANGE.(THE REASON FOR NOT MENTIONING THIS INITIALLY WAS TO KEEP THINGS CUT AND DRY AND SIMPLE.
  YES WE SAW A CHANGE BUT WHY? OUR PLAN WAS EXACTLY THE SAME SO WHY DID THE 2023 PLAN NOT WORK THIS WAY?
  FOR ALL I KNOW MAGICAL MOMENTS REPORTED DIFFERENTLY IN THE BEGINNING OF 2024.  DID MAGICAL MOMENTS SET UP THE ACCOUNT WRONG IN 2023? COULD THE TAXONOMY CODE LIST THEIR SPECIALTY AS PSYCHOLOGY WHEN THEY ACTUALLY PROVIDED ****************? IS THAT ENOUGH TO CAUSE THINGS TO GO SO WRONG? NO ONE IS HELPING ME OBTAIN ANSWERS AND I AM LEFT TO FIND THE QUESTIONS AND ANSWERS OWN MY ON.  THE WHOLE PROBLEM WITH THIS ENTIRE COMPLAINT IS THAT NO ONE WILL GIVE ME ANY REAL VERIFICATION. IM JUST TOLD WE DID EVERYTHING RIGHT AND EVERY THING IS AS IT SHOULD BE BUT NEVER AM I GIVEN ANY TANGIBLE VERIFICATION.  I HAVE EVEN SAID GIVE ME CONCRETE ANSWERS AND ILL MOVE ON. BUT THAT HAS NEVER HAPPENED.  ALSO WANT TO ADD THAT MAGICAL MOMENTS LISTS THIER SPECIALTY AS PSYCHOLOGY WHEN OTHER THERAPY PROVIDERS LIST DIFFERENTLY IN THE CLAIM DETAILS.
  OUR SON HAS NEVER SEEN A PSYCHOLOGIST PROVIDED BY MAGICAL MOMENTS.
  
  
  
  
  
  
  
  
  
  At the new year they switched insurance plan which affected their patient responsibility as it switched from a copay to a coinsurance.
  *****S PLAN DID NOT CHANGE AS CONFIRMED SEVERAL TIMES BY *****
  ALSO IT DID NOT SIMPLY CHANGE FROM CO PAY TO ************..IT IS AND ALWAYS HAS BEEN CO PAY UNTIL DEDUCTIBLE IS MET THEN IT CHANGES TO COINSURANCE.
  ATTACHED YOULL SEE THAT IN 2023 WE WERE CHARGED COPAY AND COINSURANCE AMOUNTS SO FOR MAGICAL MOMENTS  TO SAY THAT PATIENT RESPONSIBILITY FOR OUR  2023 PLAN WAS ALL COPAY IS INCORRECT
  
  
  We confirmed this with both the insurance company and with the individual alleging the complaint and in our billing records below. There was never incorrect billing, all billing per **** required the supervising provider *** on box 24J on CMS form 1500 and that is exactly what they did. There is no way to bill as a specialist, the service codes for the services rendered are not "changeable" to specialist or not. The simplest explanation here is the reality of the situation. Their plan renewal changed the details of the policy thus changing their patient responsibility amount. PLAN NEVER CHANGED BETWEEN 2023 AND 2024 AS CONFIRMED BY ****
  This simple fact can be confirmed with their insurance, we informed the individual making the complaint here of this fact
   (its completely false that we were dismissive, we spoke to him multiple times, and, during these conversations he confirmed that his insurance policy changed) 
  I CALLED ***** ***** (DOP) ON JULY 9 2024 HE TOLD ME HE WOULD RELAY THE MESSAGE TO ***** (LAST NAME?) AND I WOULD RECEIVE A CALL SHORTLY.  ***** DID RETURN THE CALL. 
  I NEVER SAID THAT *****S PLAN HAD CHANGED. AT THAT POINT I HAD NO IDEA IF IT HAD CHANGED OR NOT. AS MENTIONED SEVERAL TIMES **** HAS SINCED CONFIRMED COVERAGE FOR ABA THERAPY HAS BEEN THE SAME IN 23 AND 24.
  WHEN I ASKED ***** IF HE COULD MAKE SURE THE CODING WAS ALL CORRECT AND THE SAME ACROSS THE BOARD HE  SAID WITH A SCOFFING TONE THAT HED BEEN DOING THIS A LONG TIME, THIS CAME OFF AS BELITTLING AND DISMISSIVE..AS IF HE COULD NOT POSSIBLY HAVE MADE A MISTAKE AND THAT I HAVE NO IDEA OF WHAT IM TALKING ABOUT.
  FINALLY, ***** LEFT THE CALL SAYING HE WOULD LOOK IN TO IT AND GET BACK WITH ME.
  HE NEVER DID. I HAVE NOT HEARD FROM MM REGARDING THE  MATTER SINCE THAT DAY JULY 9 2024. SO NO, WE  DID NOT SPEAK MULTIPLE TIMES.  
  
  
  
  
  
  
  
  
  and we believe that this is a plain and simple smear campaign being conducted in sheer bad faith. 
  I AM A HONEST HARD WORKING FATHER OF AN AUTISTIC CHILD. 
  I SIMPLY HAVE NO TIME TO LAUNCH A SMEAR CAMPAIGN. AND I AM NOT A PERSON WHO ENGAGES IN ACTS OF BAD FAITH.  IN THE END I JUST WANT VERIFIED  ANSWERS BECAUSE NOTHING IS ADDING UP.  I FIND MAGICAL MOMENTS RESPONSE HERE LACKING IN SOMETHING THAT ALL THERAPY PROVIDERS SHOULD HAVE, COMPASSION AND UNDERSTANDING.
  
  
  I would not like to bring this into a public forum, please advise how we can end this matter. There will not be any refund, in fact, the individual who lodged the complaint has not even paid his dues for services provided.
  I FEEL I HAVE OVERPAID SO I NEED THIS ISSUE TO BE EXPLAINED OR RESOLVED BEFORE I SEND FURTHER PAYMENT
   The reason his insurance company took no action and he is coming here is because there was no error in billing, everything was competed as it was supposed to be. The correct resolution here would be to call his insurance provider who would be able to confirm for you that there was a policy change at the time they switched providers which resulted in a change in patient responsibility. 
  I WELCOME BBB TO CALL AND SEEK THAT CONFIRMATION. I HAVE SOUGHT IT SEVERAL TIMES.  IF BCBS COULD SAY THAT YES THERE WAS A DIFFERENCE BETWEEN THE 2 PLANS THEN I COULD PUT THIS TO REST AND SLEEP WELL AT NIGHT BUT THEYVE CONFIRMED TIME AND TIME AGAIN THAT COVERAGE IS THE SAME BETWEEN THE 2023 AND 2024 PLANS.
  Please see the attached breakdowns per the alleging party's insurance. in 2023 when they received a bill there was a COPAY this is a set amount per day no matter what, this was set at 60 (PR -3) per their insurance plan. When we serviced them after they got on their new plan in 2024, their Patient Responsibility was indicated as a COINSURANCE at 7.73 for the same services rendered, with the same CPT code. This change in amount due did not change when they switched provider, WE also witnessed this change and they received this updated patient responsibility payment from us directly. Alleging that the change accourred when they switched providers can be comclusively disregarded with the evidence provided." 
  
  
  I HAVE ATTACHED SCREEN SHOTS OF AMOUNTS OWED AT DIFFERENT TIMES THROUGH OUT 2023.  
  THROUGH OUT YOU WILL SEE CO PAY AMOUNTS ($60.. at times doubled to $120)MIXED IN WITH COINSURANCE AMOUNTS(that are usually around $12.11).  HOW CAN THIS BE  IF THE CLAIMS ARE CONSISTENT AND IF OUR 2023  PATIENT RESPONSIBILITY ARE ONLY CO PAYS AS MAGICAL MOMENTS SUGGESTS.
  ALSO NOTE THAT EVERYDAY OF SERVICE EXCEPT WHEN THE BEHAVIORAL TECHS SUPERVISOR CAME  IN TO OBSERVE ARE EXACTLY THE SAME. NOTHING DIFFERENT THAT WOULD REQUIRE EXTRA CHARGES OCCURRED.  NOTE THAT PER *****S PLAN THE TECHS SUPERVISOR COMING INTO OBSERVE COMES WITH A ************ RESPONSIBILTY AFTER DEDUCTABLE IS MET JUST LIKE THE BEHAVIORAL TECH. SO ON THOSE DAYS IT SHOULD BE AROUND $12.11 X 2 ASSUMING DEDUCTABLE HAS BEEN MET .
  ALSO I HAVE CONFIRMED THAT *****S DEDUCTABLE IS AROUND $1300 FOR 2023 2024 AND 2025 (WHICH IS MET FAIRLY QUICKLY)
  YOULL ALSO SEE A PIC OF HOW MM LISTS IN CLAIM DETAILS SHOWING THIER SPECIALTY AS PSYCHOLOGY. ***** RECEIVED SERVICES IN HOME FROM A BEHAVIORAL TECH AND THIER SUPERVISOR (AT TIMES ) BUT NEVER FROM A PSYCHOLOGIST OR DOCTOR OF ANY SORT.  
  IF BBB WOULD LIKE TO REACH OUT TO **** REGARDING THIS MATTER, YOU WILL HAVE MY FULL COOPERATION. MEMBER ID, SS#, BIRTHDATES, 3 WAY CONFERENCE CALLS ETC.
  
  Regards,
  
  ******* Still

  
  

  Customer Answer

  Date: 01/28/2025

  Can you recommend another course of action .

  Also will Magical Moments get to view my response to their message ?

  I would very much like them to read what I have to say about their response 

  thank you ,

  *******