ComplaintsforThompson River Pediatrics and Urgent Care

• Initial Complaint

  05/23/2022

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I called my insurance and verified that Thompson River Pediatrics was an in network provider prior to a well child visit for my son. At the time of the appointment, I presented my insurance card and told that it was accepted. I did everything on my part as a mom to get him the care he needed as a healthy child. I then receive a bill for $888.70. I called my insurance and they said it should be covered. The billing specialist said they would send me to collections before I could even hear back from my insurance so of course, I paid the bill in full. They could have simply referred me to a in network provider to avoid this whole problem. Normally well child visits are covered under insurance, so this is surprise billing.

  

  Business response

  09/30/2022

  ***** ****** was first seen in our office on 2/9/22 of which his mother ********* ****** presented a **** insurance card. It was a PPO plan of *********. (card is attached below) That plan was active until 2/28/2022.  That visit was covered by that plan and sent to her deductible of which she owed $149.51 and paid that balance on 3/14/22. On that first date of service she filled out our New patient paperwork which states on the Consent for treatment/financial policy agreement that Patients with health insurance plans are responsible for calling their insurance company to verify that we are in network with their particular plan before we see their child and that they are responsible for knowing what their particular insurance plan will cover and that if their insurance won’t cover a visit due to changes in their plan coverage, it is patient responsibility to pay for services. (her signed consent is attached below) There are far too many different insurance plans under each large insurance company for us to know each individual plan, which is why it is the responsibility of the patient to know their own insurance coverage.
  
  The second date of service of which we saw ***** ****** was 3/14/22. Since this was the first well child check that we were doing on her child we had him in as a new patient and for some reason our scheduling specialist sent him new patient paperwork again. So the mother, ********* ****** actually filled out the New Patient Paperwork twice. (second copy also attached below) On this second date of service she presented a New **** card (attached below) that is for a Catastrophic plan. Catastrophic plans do not cover well care. ********* stated to my front desk that she had contacted her insurance company and that they told her that they did in fact cover well child care. So, they scanned the card into the chart and we billed that visit to the new **** plan which was only valid for one month from 3/1/22-3/31/22. That plan returned the denial to us on 4/26/22 that in fact that plans benefits don’t cover that kind of care, referring to well child visits. The Claim information pulled from ****’s website is also attached below.  The total due was then the responsibility of the mother, ********* ******. The total for that visit, that included very expensive vaccines, was $1,446.70.
  
  After receiving the statement for the visit and speaking with my billing specialist Kelli, ********* gave her a new **** insurance ID number: ************, which I do not have a copy of the card because she gave it to her verbally. ********* then initiated a phone call between **** and Kelli with this new plan regarding the visit asking them to cover it. Once kelli gave them the Date of Service for the visit, which was in March, the representative on the phone told Kelli that this new plan was not active until April 1st and therefore we would not be able to bill the visit to this new plan.
  
  To sum it all up, we out of a courtesy to the mother, reduced her bill down to $888.70 which was the cost of the vaccines and the supplies that we used that day on her child. We wrote off the providers time and all other costs of the visit for her, which we were not required to do. So as far as her asking for a billing adjustment, one was already made. Also, the new surprise billing law applies to hospital billing and not outpatient offices. The part of the new law that applies to us is for uninsured patients and giving them a good faith estimate ahead of their visit, which we do every time we see uninsured patients. 
  
  Please let me know if there is anything else that you need from me as I would be more than happy to help.
  
  Amber G******, CMBP
  CEO/Owner
  Thompson River Pediatrics
  ******* ************ ***** ************ **** ************
  

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