Complaints

• Initial Complaint

  06/16/2022

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  I have used this provider in the past for assistive devices following a partial foot amputation. My medical coverage is accepted and I have never had any billing issues with them.. suddenly, with regard to my permanent prosthesis, a custom silicone foot. They refuse to produce or even start the production process, and have stalled the processes claiming they need a code or rate of payment from my insurance company, and have caused me severe pain, anguish and stump degeneration as a result. They refuse to return calls, have verified (as well as my proving and providing verification) of coverage. However, they are using a stalling tactic that appears that they are holding me medically hostage for payment from the insurance company. When my benefits guide clearly states that they cannot refuse services for covered benefits for ANY reason. I will be contacting the states medical board, and am currently working with my care manager at the insurance company to tey to expedite the process. I have waited 6 months POST coverage verification without any reason, therefore I consider it a refusal of covered services/products and the cause for damage to my phusical being as a result and regard it as intentional.

  Business response

  06/17/2022

  Hello *****,

  We have done everything in our power to get the new silicone prosthesis approved, but when working with ******** we must obtain an approval and exact dollar amount of what they are going to provide for the prosthesis before we can fabricate and make it. The code for this type of prosthesis is a miscellaneous code, meaning they typically never pay for this and have no dollar amount attached to the lcode. Making this very difficult. So, we must clarify and see what ******** is willing to pay before we can move ahead. This gives us what the total allowed amount is from ********. Once we know this we know if they will cover the cost of the prosthesis. We have been working with insurance companies for over 75 years and are very familiar with the process.

  If you are not happy with our services, we would be glad to provide other providers for you to see. We want you to be happy and taken care of. But we have been doing everything in our power to help get this approved for you. We cannot control the insurance company and must follow their rules and regulations and at times that process can take several months to get a final definitive answer. I know that may be frustrating to you as a patient but that is out of our control.

  So, I think it is unfair to say we are refusing service and stalling the process and using “stalling tactics” intentionally causing you pain. That is false, and we are not by any means holding you hostage and you are free to see whom ever you would like.

  Finally, you from our clinical notes it has only been 3 months not 6 months and are not refusing anything, the complete opposite trying to help you. It has been 3 months since we started this process and spoke of seeing if we can get you a silicone prosthesis, which at the time you were specially told they are very difficult to get approved and ******** has never paid for them prior, and if they do pay it can take up to several months. Second, we have called and emailed you with updates on all this information before, so none of this is new. I understand you want the silicone prosthesis asap, but we must wait for approval and work with the insurance company.

  Thank you,

  Leimkuehler Orthotic-Prosthetic Center, Inc

  Customer response

  06/17/2022

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
  
  [To assist us in bringing this matter to a close, we would like to know your view on the matter.]
  
  Regards,
  
  ***** ****
  I am not satisfied with the response solely because the issue is not resolved. Regardless of the process the are required to complete, there has NEVER been any email or return phone calls from the provider, let alone a stsus update. I have had to contact ********** each time to obtain any form of status update. The bottom line is that per ********* it has been verified as a covered service and product so delaying the manufacturing of the device is not necessary as they are demnding a rate or percentage of payment which in my case is 100% covered of the total price, whatever that is. So as it stands they still has a misunderstanding that I am covered by not regular ********, or **********, but ********** ABD for aged blind and or disabled individuals which affords the covereage for 100%of all prosthetics.

  Business response

  06/20/2022

  The issue is still being worked on currently and takes time as mentioned before and cannot be instantly resolved. We must work with ********** to get everything good to go. There have been seven phone calls to get a definitive answer from ********** and is still in the process. Talked to Kendra from ********** on 4/8/22. We spoke with Linda at ********** on 4/15. Spoke with Darren twice in April. Spoke with Jamie from ********** in May. Darren again in June and we could not get a definitive answer from any of the ********** representatives.

  You are right you are covered at 100% for yourself and will not owe anything, that is how ********** always works for their members. We are very familiar with that. However, that doesn’t mean they will pay for what the prosthesis costs us to make. Two completely sperate things. They say it is approved but cannot give a dollar amount of the coverage for the silicone restoration, as they do not normally approve miscellaneous codes, which we need to be able to understand our costs. We need to see if they will cover our costs for the work and prosthesis we will have to make, as it is not free for us. Once we have that information, we can have a more definitive direction to go.

  We have also provided you with a definitive prosthesis on which CareSoure paid for back in August of 2021, which is not that long ago and had over 8 different appointments for that prosthesis from June to August that we worked with you on. Again, if you are not happy with our services, we would be glad to provide other providers for you to see. We want you to be happy and taken care of. But we have been doing everything in our power to help you.
  
  Thank you,
  Leimkuehler Orthotic-Prosthetic Center, Inc

  Customer response

  06/20/2022

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
  
  [To assist us in bringing this matter to a close, we would like to know your view on the matter.]
  
  Regards,
  
  ***** ****
  I am still in the same position as before. As the covered patient, I have waited months. Regardless of the cost coverage for you, it still needs to be produced and putting a patient at risk is not sitting well. It is my understanding after speaking with ********** numerous times, this is not something that should delay or cause harm to a patient. You cannot deny services for covered benefits under Ohio and ********** regulations at any given time. So, no I will not be looking for another provider. If your office cannot or does not know how to acquire the information you need, it has nothing to do with my claim, services or covered devices. There has been ample time allowed to obtain it, and I feel that the time taken to acquire it was adequate. Again being held from a covered service or device based on your inability to acquire information from an insurance or benefit provider need not fall onto the patient. I have spoken with them numerous times and I have printed material stating that you cannot delay or refuse to provide covered services for any reason. Please resolve whatever your issue is, but I will not bear the damage of your unwillingness to provide services.

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