ComplaintsforSalem Periodontal Specialists

• Initial Complaint

  01/27/2023

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Answered

  More info

  I had "pre-authorization" for periodontal procedure. Procedure done : 11/09/2020. Salem Periodontal Specialists (SPS) did not submit claim until 10/12/2021 (1 year later). Then GEHA dental insurance did NOT process the claim until 11/19/2022. During this LONG period, SPS staff advised us MULTIPLE times NOT to worry; we had paid our portion; it was between them and the insurance company. ***************** requested additional info from SPS; they (SPS) did not appear to be able to produce the information; missing x-rays and files. Now SPS has turned the insurance amount ($2,636.66) over to collections. I understand my financial responsibility. But I believe that SPS has NOT conducted themselves in an ethical manner with regards to this account. I am also filing a complaint with the ****** *************

  Business response

  02/09/2023

  The patient did not request a pre-authorization to be sent to the insurance.  It is not our policy to send pre-authorizations to the insurance unless requested by the insurance.  The claim was submitted right away, however it was in deed missing an xray that their insurance did require.  We were able to get the xray and resubmit to the insurance.  There was a lot of back in forth with the insurance but our policy as signed by the patient is the balance is ultimately the patient's responsibility regardless of insurance coverage that we bill as a courtesy to our patients. We did our best to work with their insurance even though it was just a free courtesy we offer our patients.  We have finally received insurance payment 1/2023.  Most of the procedures that were completed was not a covered benefit with the insurance.  I had reached out several times to the patient regarding the account balance in which the patient and wife refused to make any payments.  The patient had several dates of treatment that was in deed sent to insurance and paid by insurance but they were not willing to make their patient portion. The patient then threatened us with an attorney regarding the patient balance continuing to bring up the "non covered services" that their insurances deemed and that we did not do our part with the insurance to get these covered when in fact they are just not a benefit of the policy.  I have gone back in forth trying to work with them stating that one of the services that *** have been covered by the insurance that the insurance deemed "not enough clinical evidence" for the procedure to credit them what insurance would have paid.  I offered to also remove all late fees associated with the account that are charges from 2019-2020.  The patient is still not happy and does not want to pay their patient portion at all.  They have made no attempt to pay anything on the account or set up any payment arrangements.  All of this came about after I told them that we needed to collect this past due amount which I have no notes or documents stating that have been in recent contact, or i was going to send them to collections.  Please see all documents attached.  This is just a patient that does not want to pay their bill and is angry with the amount their out of network insurance paid unfortunately.  I have gone above and beyond to work with this patient and resolve the issue including extending the time needed to review the account asking what we can do to help, offer payment plans that is NOT our policy to offer but to help them out.  I have sent multiple emails with them just asking the same questions over and over and bringing up us not having the claim sent correctly the first time.  I feel after 2-3 years of working with the patients on this claim that we have done our due diligence to assist the patient with their insurance company who we are not affiliated with at all.  I have more information if you would like to see it.  

  Customer response

  02/11/2023

   
  Complaint: 18942000
  
  I am rejecting this response because:

  1.  WE DID REQUEST THAT SPS OBTAIN PRE-AUTHORIZATION from the insurance company and were provide a document from SPS that indicated the insurance benefits.  We would NOT have proceeded on such as major procedure without the confirmation; that is WHY we pay insurance premiums;  we would have found a different dental provider!!!
  

  2.  During the "the two years" we were assured numerous times by SPS that everything would be fine; "THEY" were working it out with GEHA and we had "nothing to worry about"!  ... "due to COVID", things were slowed down!
  

   

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

• Initial Complaint

  06/29/2022

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  On January 4, **22, **************** *************) did a bone graft on my #** charging me $1547. My insurance denied it saying it was an "experimental procedure". On May 11, I went to **************** *************) for implant consultation. He found the bone graft not done properly and sent me back to ****************. Insisting that everything was all right and as planned, **************** decided that membrane should be removed on May 12, and further charged $91 (later reduced to $52) for it. As, according to ****************, **************** did not get the bone graft right, and had caused me additional pain and suffering, I'm asking that he refund his charges for the #** bone graft.

  Business response

  08/01/2022

  To whom it may concern,
  Thank you for contacting our office regarding this matter and for considering our experience as well. Patient  ************************* came into our office with a severe infection on the lower left jaw bone and missing teeth posterior to the one that had to be extracted. Patient Yannan wanted an implant, but due to an anatomical consideration (nerve) the patient needed of ridge augmentation (Bone Graft CDT code D7950) . We presented an estimate as the patient responsibility for the treatment plan, after insurance payments and discounts. There was further discussion of the estimated out of pocket cost, and it was reiterated to the patient that this was merely an estimate and that we could not guarantee insurance payment. The patient was then offered a 7% discount off denied services in the event the claim was in fact denied for any reason.  
  When the patient presented for services, Insurance was billed with codes D7950 Bone replacement graft for ridge augmentation per site for the initial treatment visit. The claim was subsequently denied, attributed to the codes not being used in conjunction with an implant, which is not the proper procedure steps.  The patient was understandably upset and demanded that **************** write off a minimum of 50% of the treatment cost, stating that all further treatment would be cancelled until till this was resolved.  
  In the meantime, our office and the patient both appealed the claim to insurance. The appeals were again denied on the basis of being experimental, which this is not an experimental code.  Despite the patients benefit summary listing code D7950 as covered at 80%.  As a result the patient failed to present for his subsequent appointments, thus *************** was unable to provide necessary post op and follow up care, including membrane removal. 
  Upon consulting **************** for a second opinion, it was indicated that the original services provided were not adequate. **************** is not a specialist and does not know what type of procedure **************** did. The patient then revisited our office to discuss the supposed inadequacy of his treatment, at which time was reminded that he failed to present for necessary post-op and follow-up treatments, thus the procedure was not delt with adequately as the patient did not show for his prior appointments to remove the barrier membrane, Patient did not visit our office for 3 months, the bone graft was done properly and had extra volume of bone for implant placement. 
  We discussed the remaining implant portion of the treatment, Yanna constantly was haggling about cost reduction and kept my staff occupied for several hours. The patient agreed and an appointment was made for the implant.  Which then *************** offered a $500 discount for the implant.  A couple days later, the patient again contacted our office regarding his dissatisfaction with the denied bone graft claim. Upon further discussion of the matter with ****************, it was determined that our office was just not a good fit for this patient. The patient was contacted and thanked for being a patient with Salem Periodontal Specialists and told that we felt he would be happier with another provider. 
  Please let me know if you have any further questions regarding this matter or would like copies of estimates, treatment plans, or communication from insurance for reference.
  

  Sincerely,
  
  
  ****************
  Office Manager
  Salem Periodontal Specialists, PC

  Customer response

  08/02/2022

   
  Complaint: 17501722
  
  I am rejecting this response because:

  As I stated in my 6-6 letter (attached, again) to them, the two appointments I canceled was not for "membrane removal" as they claimed.  The **** was for "cone beam capture", and the **** was for implant.  I was never scheduled for "membrane removal", not until **************** found ******************** $2000 bone graft not fit for implant (Pa 5.11.2022.jpg, as found by ****************).  Another instance of ******************** shabby work was: when he removed the suture after the bone graft, he left one suture behind, until my own dentist ********* cleaned up his mess (and told ****************). So when **************** sent me back to **************** to "redo" or "repair" on ****, **************** removed the membrane.  When I asked him whether that (membrane removal) had been planned for, he said yes,but as I mentioned just now, I was never told or scheduled for such a procedure. Then,without my knowledge or consent, he charged me for the membrane removal. Overall, I have lost confidence in him, and have decided against continuing with the implant even though he offered a $500 discount. While he was removing membrane, he mentioned that he had a communication problem with me. For the record, I wrote him four letters, of which he never wrote me back. ****** did call me two times, but she never responded to my **** one in which I asked him for an explanation of the additional, unauthorized charge on ****.  As I said, he already  harged me $2060 (later reduced by you to $1547, but was still denied
  by my insurance for its being "experimemtal procedure". Now additional charge for removing membrane, and without my knowledge or authorization?  What kind of doctor is that?
  
  Sincerely,
  
  *************************

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