Complaints

• Initial Complaint

  07/12/2022

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  My insurance denied coverage due to lack of clinicals, and no one is responding to me in regards to my deposit refund. Please advise.

  Business response

  08/22/2022

  Business Response /* (1000, 5, 2022/08/04) */ Timeline of*************** case from our Biller ******* who has handled this case: 8/27/2021 Authorization request was faxed to ***** with clinical documentation 9/7/2021 Authorization was denied 9/21/2021 PTP option has expired, now a written appeal is necessary 9/29/2021 I spoke with ******* at ***** and requested a faxed copy of the denial letter, we had still never received a copy via mail or fax 9/30/2021 (Attached) Sent appeal via fax to *****, and marked as Urgent 10/5/2021 S/W ****** at ***** and was told the appeal has a positive outcome and our anticipated surgery was "partially" overturned. Only approving Legs *****, but still denying Arms ***** 10/5/2021 Emailed the patient with the update, now awaiting the faxed letter from ***** During this the patient had postponed her surgery from October 2021, to April 2022, the 8th. 3/8/2022 (Attached) Reached out the patient,************* via text that her surgery was partially approved. I also emailed her a copy of the letter we received from ***** dated 10/13/2021, stating the partial approval. 4/12/2022 Since the last correspondence the patient cancelled her surgery and was requesting her "non-refundable" $1,500.00 deposit back. She was aware it was non-refundable. I was on a call with *****,******** (Office Manager) and *********** discussing this, Approval and supposed denial the patient was being told by *****. For 35 minutes we were all on the call and even the ***** rep could not bring up the letter we received from ***** stating the partial approval, and she could not explain WHY. But she did agree if we have a office policy of a deposit being non-refundable then what was the issue, and proceeded to hang up on our call. Please see the letter dated 10/13/2021 faxed to me from an ***** employee named ***** (call made 10/13/21 ref# **********), ***** stated to me the approval was for 10/8/21-4/8/22 and the legs only were approved, ***** X2 units. This letter was emailed to *********** on 3/8/22 and 4/12/22 for her records. Page 5 of the entire fax (labeled Page 4 of 16 in the top right corner) 2nd paragraph states "After reviewing the information above, we are standing by our decision to uphold the original benefit determination for services rendered suction assisted lipectomy; upper extremity (*****) and unlisted procedure (*****). However, we will allow suction assisted lipectomy, lower extremity (*****)" We have no reason to not assume that there was an outstanding denial. Nevertheless the patient cancelled her surgery, of her own decision.

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