ComplaintsforPlanned Administrators, Inc (PAI)

• Initial Complaint

  11/02/2022

  Complaint Type:

  Billing Issues

  Status:

  Resolved

  More info

  I have several problem with several of my claims with PIA. I called several time to solve these problems. Some of them they admitted their fault and I am hoping they will solve. For two other claims, when they try to fix the problem, they are sending more payment to the hospital BUT THEY ARE ALSO MAKING ME PAY MORE. How can it happen? I have uploaded several documents below. In the claim with claim # XXXXXXXXXX, total charge is $1,947.00. They received $932.38 as provider discount. They processed it at 40%. Insurance company paid $405.85, and my responsibility was $608.77. When I called and asked why this is processed at 40% instead of 60% (because this was in-network provider.) When they repocessed the claim (claim # XXXXXXXXXX). Now they reflect $251.16 a provider discount. They are processing it at 60% and paying $1,017.50. and my responsibility is $678.34. I am puzzeled when they processed again WHY suddenly (and misteriously) provider discount is going down from $932.38 to $251.16. I am assuming provider discount should not change. Very same thing happened in another claim. Claim with claim number XXXXXXXXXX Total charge was $4,973.00. provider discount listed as $2,966.27. insurance company paid $469.58 and my responsibility was $1,537.15. When I called and asked why one item in the bill processed at 40% while others are processed at 100% and 60%. They repocessed it. And in the updated claim (claim# XXXXXXXXXX) Provider discount suddenly went down to $641.51. Insurance company paid $1,883.92 and my responsibility increased to $2,447.57. Again WHY when I complained about the claim suddenly (and misteriously) provider discount went down from $2,966.27 to $641.51. (now in the updated claim, they are paying more, and I am also paying more. I am puzzled) There were mistakes in 5 other claims of mine. They are doing fishy practise.

  Business response

  11/09/2022

  Business Response /* (1000, 5, 2022/11/07) */ This member's concern is about claims that processed out of network. After reviewing all of his claims for the year, we found there were claims processed out of network. Some of these claims have already been priced through First Health and reprocessed in network. However, once pricing was received, the allowed amounts and discounts changed. The member is questioning why his patient responsibility would increase when the claims are reprocessed in network, but the original pricing the member saw on the initial claims wasn't valid. The pricing we receive from the network would be accurate. While some claims have been reprocessed through First Health, there are other claims on this policy that are still showing out of network. During our investigation of his claims, we found he had a network change earlier in the year. He went from the Preferred Blue network (used only by SC residents for services rendered in SC) to the First Health network (used by all residents outside of SC and SC residents when receiving care out of state). Due to this change, we communicated with the group to confirm where he has been living to verify his claims are going through the correct network based on the date of service. The group contacted the member directly about this and the member advised he has lived in SC for all of 2022. We were initially given the dates below and advised the member would be living in SC and TX this year during different time frames. With the new information that he has not moved out of state this year, we have backdated this update to reflect the member being on the Preferred Blue network for all of 2022. We will be pricing and reprocessing all of his claims that processed out of network or through the First Health network (as long as the services were rendered in SC; if services were rendered out of state the network would remain First Health) as these need to be reprocessed using the Preferred Blue network. Once the claims have been reprocessed, the member and providers will receive new correspondence from us in the form of EOBs and necessary payments. This is a self-funded group and the Human Resources Group Leader Marissa communicated the following to us about this member's residence. 8/20/21- we were advised the member moved and should be on FHP starting on 7/31/21. 5/31/22- we were advised member is moving back to SC/Preferred Blue starting 5/30/22-8/19/22, then back on FHP from 8/20/22-12/31/22, then back to Preferred Blue starting 1/1/23. Dates provided by the group: 10/1/20 - 7/30/21 - Preferred Blue 7/31/21 - 5/29/22 - First Health 5/30/22 - 8/19/22 - Preferred Blue 8/20/22 - 12/31/22 - First Health - Per e-mail from Marissa member would be utilizing out of state Network during this time frame. As of 1/1/23 forward Marissa stated he would be back to utilizing Preferred Blue. Consumer Response /* (2000, 7, 2022/11/07) */ (The consumer indicated he/she ACCEPTED the response from the business.)

• Initial Complaint

  06/13/2022

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  They are denying necessary medical care for an issue that has been ongoing for 14 years. They are harassing us and our doctors for documentation that has been provided the entire time. They bought a Thomas Cooper and have been horrible ever since.

  Business response

  06/27/2022

  Business Response /* (1000, 13, 2022/06/27) */ Pai has reviewed account but there was not much information on who or what the issue is for on the account. However, PAI has recently reprocessed claims after a medical review was completed and approved. Any additional information can be obtained by calling our Customer Service line at XXX-XXX-XXXX. Thank you.

• Initial Complaint

  06/13/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I filed an appeal with the insurance provider to where my daughter was denied coverage for a covid-19 hospital visit. My daughter has Medicaid, but this provider denied my 1st claim in reference to my employer didn't have her social security number under my coverage for us that the provider was taking weekly payments from my check up until 02/01/2022, then my assignment was over with ************ Concord, NC. So, they sent me the denial of the appeal telling me in writing,"however; you were not eligible for benefits under this group health plan for the submitted date of service because your coverage terminated September 6, 2021.

  Business response

  06/28/2022

  Business Response /* (1000, 8, 2022/06/22) */ We have sent a response to the member stating that there are no deductions on file therefore the member never had coverage for our Indemnity or MEC preventative plan. Our letter advised the member that no deductions were on file and if he had check stubs showing deductions to submit to us for review. Consumer Response /* (2000, 10, 2022/06/23) */ (The consumer indicated he/she ACCEPTED the response from the business.) I accept the response because she has Medicaid.

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