ComplaintsforLemme Audiology Associates

• Initial Complaint

  01/06/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I was referred from my primary care physician for a Vestibular test, my physician contacted Lemme by phone and then sent them a referral for me asking them if they accept the insurance the patient currently has, the office at Lemme stated they do. I arrived for my appointment on 11/30/2021 and befor I was seen I filled out their paperwork and presented them my health care insurance card and I again asked them if they'd pre authorized this test to make sure my insurance was approved and to cover the test, I was instructed, yes they do take my insurance and they accepted the co pay that is associated with my insurance. I recently got a bill from a collections agency stating I owe Lemme Audiology $396.38 do to my insurance denied them payment since they are out of network. I asked Lemme, why I am being billed and I was told they do not take my insurance. This is why I wanted to know if they pre authorized this before my testing. They took a copy of my insurance card knowing that they don't accept that insurance and never said to me that they do not accept my P.E.B.T.F. health insurance. That was a clear bait and switch and now they want me to pay them from my own pocket for there mess up. I called Lemme on Jan 3,and Jan 5. They offered to take 50% off the $396.38 making my bill to be $198.19. Again, why would they say they take my insurance just to find out afterwards they don't take it. The RED flag should have been when I presented them my insurance card for them to say sorry we don't accept P.E.B.T.F. or maybe they should have pre authorized this like they supposed to before my appointment. They know they are in the wrong, especially since they offered to lower my bill by half the original amount.

  Business response

  01/17/2023

  January 12, 2023 
  *** ********* *** ******** 

  Nov. 10, 2022 Dr. Ol***** office called and asked if we accept Geisinger insurance (possible PEBTF as well). Our front office said yes. (We have been billing both for years). They then scheduled *** ******* for vestibular testing on Nov. 30th, 2022. The front office asked for an order/referral for testing from the physician's office and it was sent to us via fax on Nov. 15th, 2022. 

  Att;1 the order for vestibular testing prior to visit, it states he is being referred to us through Geisinger outpatient system to perform audiology/vestibular testing. 
  Att;2 Cover sheet he signed Nov. 10th 8:05 pm. It states to remember to bring your insurance cards and a referral to the appointment if your insurance requires one. Co-pays are due at time of visit and if any portion of the testing is not covered, you will receive a balance bill from our billing department after your insurance has processed the testing. 

  Nov. 30, 2021 *** ******* came to the appointment and upon checking in signed a service charge form. He may have asked if we received the referral for the appointment and the front office most likely said yes. Had he asked if we "pre-authorized services" we would have told him we received a referral/order for services. We have never needed to pre-authorize services for Geisinger or PEBTF insurance. The patients HMO physician office must submit for pre authorization if needed for insurance plans. People who have this insurance know they need a pre authorization and are mailed the approval or possibly receive a copy online previous to the appointment. 
  Att; 3 Service charge form. I understand there is a charge for the medical services and/or diagnostic testing that I have agreed to have done above. I also authorize release of any information to process my medical insurance claim(s). I also understand that I am responsible for the co-pay, deductible, cost share or payment in full if my insurance will not pay for any reason. 
  *** ******* insurance PEBTF was processed for his services/claim and attached is the explanation of benefits received from his plan. 

  
  Att; 4 Explanation of benefits from PEBTF. This states he is 100% responsible for $1128.00 in services rendered due to not staying in network. 
  Our billing department lowered *** ******* services to what Geisinger (who processes his PEBTF claims) would have paid if in network $396.38 on the approval of management. He was then mailed a bill for services on three occasions, Jan. 20, 2022, March. 15, 2022, May 2022 and August 2, 2022 stating if he did not pay in 15 days his bill will be sent to collections. He reports he did not receive any of these bills. These were sent to the same address as he currently has marked down on his paperwork and 
  
  *** ****** **** ********** ******** ** ***** **** *** ******* **** ***** *** ********** ** ***** ****** ***** ******** **** ***** ******** 
  the same address as the collections company was given on Dec. 19, 2022. The Collections Company mailed him a bill to that same address, which he states he received. 
  *** ******* called on Jan. 3, 2023 stating he was "pre-approved" for his visit and he should not have been charged. He stated his Dr office called his insurance and set up the approval with him there. He stated if he had gone to Danville G******** his services would have been covered. He said he knows he has to stay in his network through his insurance. Based on what we now know, he must obtain services through Geisinger owned clinics. We have seen other PEBTF patients in the past and pre-authorization was not required. We were not aware of any PEBTF insurance's requiring any "pre-authorizations" and his insurance cards did not indicate that this was necessary. 
  On the conversation Jan. 5th, 2023 I told him that I would talk with the owner to see if she would lower the bill any lower. I really did not talk with the owner but out of compassion I told him she would lower it to 50% and called him to let him know to pay $198.19. I did not do that because I believed we did anything wrong as he states. I believe we did everything correct as a business, doctors office and billing. 
  I have sympathy for *** ******* but ultimately the patient is responsible to know their insurance plan and coverage. Yearly they are given rules to follow for making appointments with HMO, diagnostics, specialists and hospitals. They have to follow their rules. Since he knew he needed a pre-approval for services, he should have waited until he received a copy of the pre-approval to schedule for an appointment. We received the referral from his physician prior to the visit which was our requirements.

  For over 10+ years now we have not had any pre approvals needed by any insurance for anything done in our office so the front office would not have known his required this to be done. They would not have known by seeing his insurance card that he would have needed it as he stated or that it would be out of network. We see different PEBTF and Geisinger (claims processing for his plan) every day. 
  Copy of insurance card. On the card it states No HMO Referral. We did not take a copy of his insurance card knowing his plan is out of network or possible required a special pre approval previous to services as he states or as a "bait and switch". 
  
  *** ****** **** ********** ******** ** ***** **** *** ******* **** ***** *** ********** ** ***** ****** ***** ******** **** ***** ******** 
  I do not believe that we are responsible for the denial by his insurance. He stated he knew he needed pre authorizations to be seen and that he normally receives the approval from insurance before the visit. If he did not receive this same approval, he should have canceled the appointment and called his HMO asking if it was submitted. According to my billing person, even with a preauthorization his insurance probably would not have paid since his plan would have required him to stay within the Geisinger network. 

  
  The bill was lowered to help him out, and not because we were to blame for the oversight. Had we known he would see this as our admission of guilt, I would have required he pay the amount his insurance applied which was $1128.00. He did report he was happy with the testing and the results he received through our office. 
  Please let me know if you require any further information, or have any further questions. 
  
  Thank you, 
  Give 
  Jill G******* *IS Director of Operations 

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩