ComplaintsforSimplan Administrators Inc.

• Initial Complaint

  02/15/2022

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  On May 23, 2021, I went to Baptist-St. Anthony's Emergency Department in Amarillo with a medical problem. I was billed for $3,455.51. Simplan is the administrator for my healthcare plan and Cigna is the insurance carrier. Cigna initially denied coverage, but I appealed. I received an Explanation of Benefits from Simplan date Nov 4, 2021 (attached) showing the bill was paid. However, I continued to receive bills from BSA stating the bill was not paid. I contacted and tried to contact Stephanie ****** at Simplan ************* ***** numerous times. She replied to a couple of emails, but hasn't responded to additional inquiries since Dec 3, 2021. On Jan 10, 2022 I spoke to Frank ************* ****** and he told me that Check #3723 was issued in the amount of $2158.70 was mailed on 12/24/2021. However, Baptist-St. Anthony's billing office continues to state that the bill is unpaid. Yesterday I got a letter from a collection agency regarding the bill. I tried again to contact Simplan. Frank at Simplan told me that Ms. ****** would call me back by 1:30pm. She did not call, and does not pick up her phone or answer my emails. I would like to know why the Explanation of Benefits indicates the claim was paid, and yet Baptist-St. Anthony's has turned the bill over to a collection agency. If the bill has not been paid, I would like Simplan to make sure that it gets paid. Thank you

  Business response

  02/22/2022

  Business Response /* (1000, 5, 2022/02/22) */ Simplan is the TPA, or third party administrator, for the partially self-funded ERISA employee benefit plan that this participant was enrolled in May of 2021. Simplan is required to process all health care claims in accordance to the policy and benefit plan that is established by the participant's employer. When theclaim was originally received, it was pended for needing a copy of the Emergency Room Notes. Once received, the claim was denied due to the policy exclusion of non-emergency use of an emergency room. When the participant contacted Simplan regarding the denial, he was provided with a copy of the medical records from the facility, of which was used to determine the non-emergency use of the emergency room. The participant indicated that the medical condition was severe and required emergency medical care, and that he would be contacting the facility regarding the medical records, and as a courtesy, the claim was processed for payment, and placed on hold, pending the additional documentation that was needed to allow the claim to be eligible to receive benefits. The participant did contact the facility in December 2021, informing them that they needed to recode his claim as a life-threatening medical emergency, and the facility indicated they would review the details on the account. Upon completing their review, no additional information pertaining to the patient's visit could be added that hadn't already been provided in the medical records. On 02/16/2022, Ms. ****** emailed the participant requesting that he supply the additional information that would elevate the use of the emergency room to a life-threatening medical emergency, since the facility had no additional information to provide to show the severity of his diagnosis. Ms. ******* nor Simplan, has ever received any documentation that would allow the claim to be eligible to receive benefits. On 02/18/2022, the participant emailed Ms. ****** and indicated he had paid the balance of the claim to the facility. Due to HIPAA, no additional details will be provided in this response pertaining to the diagnosis or the reason the facility emergency room was used in May 2021. Consumer Response /* (3000, 7, 2022/03/02) */ (The consumer indicated he/she DID NOT accept the response from the business.) I cannot accept that trismus (lockjaw) does not qualify as loss-of-function, which is the criterion for my policy. Any number of emergency room visits are emergencies, but not life-threatening. Examples include kidney stones, broken arm, scalp laceration, dislocated shoulder, diverticulitis, breast abscess, etc. I paid $27,000/year for coverage, and failing to cover emergencies is completely unacceptable to me. The reply from Simplan does not address the concern that I was given supplied by Simplan with a check number, along with a mailing date, which caused me to believe the claim was paid. Since I thought the claim was paid, I did not pursue further action. As a result, my account was turned over to a collection agency, damaging my credit rating.

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