ComplaintsforMedical Mutual of Ohio

• Initial Complaint

  06/13/2022

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  After a visit with my PCP, I was advised to get an eye exam because I had not had one since childhood. Before making the appointment I asked my wife to call Medical Mutual to check on my coverage. My wife called Medical Mutual on March 28, 2022, and spoke to Natasha. After checking my benefits, Natasha told my wife that I was covered 100% for an eye exam annually. My wife asked her repeatedly to be certain and Natasha replied each time that, yes an eye exam would be 100% covered. Having that information, I made an appointment at the ********* ****** and went and had a standard eye exam. Several weeks later, I received a bill from the ********* ****** for the total cost of the exam, a whopping $548.00! Shortly after that, I received my EOB from Medical Mutual stating coverage was denied with note #G22 - Benefits are not available for vision services. I was not having any vision problems and I certainly would NOT have had an exam if I wasn't assured that it would be 100% covered by my insurance. I am filing this complaint with the BBB to help resolve this issue. I pay Medical Mutual an ungodly amount of money every month for coverage and THEIR REP gave me false information that is now causing me anguish over getting hate letters from ********* ****** to pay a bill I never would have gotten services for except the fact that Natasha, the Medical Mutual representative on March 28. 2022 said I was fully covered. Please refer to call reference # ************* to listen to the recording and see that we were given misinformation. I expect Medical Mutual to make good and pay that bill as this is the covered I was told I had and now they are refusing.

  Business response

  06/15/2022

  06/15/2022
  
  Better Business Bureau
  200 Treeworth Blvd
  Broadview Hts, Oh 44147
  
  RE: ID # ******** ***** ******
  
  Dear Ms. Angel:
  
  I am writing to respond to the complaint forwarded from your office on 06/13/2022. Mr. ******  states his wife called Medical Mutual on 03/28/2022 and was advised that his eye exam would be covered at 100%. He would like the call reviewed and the claim paid.
  
  We received a claim for an eye exam for date of service 4/6/2022, which was denied on 4/20/2022 as benefits are not available for vision services. Rules from your certificate, summary plan description or evidence of coverage were used for this determination.
  
  On 5/18/2022, Ms. ****** called to inquire on the denied claim. We advised Ms. ****** to appeal the claim.
  
  On 06/13/2022, we received an email from Mr. ****** who stated he filed an appeal in May and wanted to know the outcome. There was no appeal on file and we advised Mr. ****** to file an appeal.
  
  On 6/13/2022 we received the Better Business Bureau Complaint. Since we do not have an appeal on file, we made an exception to initiate an appeal based on this complaint. The call on 03/28/2022 was reviewed and we did not advise Ms. ****** that we would pay the eye exam at 100%. We advised her that vision was not covered under the medical plan and that she should contact the eye exam insurance provider, which is *** ********. The claim denied correctly based on the medical benefits. Mr. ****** will receive a separate letter regarding the outcome of the appeal.
  
  Mr. ****** should reach out to *** ******** with his concerns.
  
  If you have any questions, please don’t hesitate to contact me.
  
  Sincerely,
  
  Holly P******
  Customer Resolution Specialist
  Appeal and Complaint Department
  Fax (216) 687-7990
  
  

  Customer response

  06/16/2022

  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,
  
  ***** ******
  
  The response from Medical Mutual is loaded with misinformation.

  First, they did NOT review the call on 3/28 with Natasha. Natasha clearly stated that I was covered multiple times. The phone was on speaker and I heard the entire conversation. The call MM is referring to occurred on 5/16 with Pat where she stated the claim was denied and suggested contacting ***. Which we did and spoke to Vorica.
  

  On 5/18 We spoke to Sandra and she was the one who suggested filing an appeal which we did that day online. MM claims it was never received, but after reading reviews on this site it appears it was probably just deleted and ignored. I did file another appeal when i was told the first one was not received.

  Again, I must state that the reason for the call to Natasha was to see if I was covered for the exam. Natasha gave me FALSE information and now MM will not make good on their mistake. I would have NEVER made any appointment that was not covered. Now I am supposed to pay the bill out of pocket. I suggest that the phone calls and other evidence be preserved for further action against Natasha and MM. I have attached a photo of the notes taken when the calls were made.

  ***** * ******
  

  Business response

  06/20/2022

  06/20/2022
  
  Better Business Bureau
  200 Treeworth Blvd
  Broadview Hts, Oh 44147
  
  RE: ID # ******** ***** ******
  
  Dear Ms. Angel:
  
  I am writing to respond to Mr. ******'s additional concerns. Medical Mutual initiated an appeal regarding the denied services. The phone call on March 20, 2022 was reviewed for a possible benefit misquote. The customer care representative advised that you do not have any coverage for vision under your medical benefits with Medical Mutual. Your spouse then advised that you have *** through *****. The customer care representative then advised your spouse to contact *** directly. The customer care representative never advised that vision was covered under the medical benefits. Therefore, no misquote occurred.
  
  We encourage you to review the letter sent to you dated June 15, 2022 which provides you the next steps in the appeal process. We have attached it for your convenience.
  
  Sincerely,
  
  Holly P******
  Customer Resolution Specialist
  Appeal and Complaint Department
  Fax (216) 687-7990

  Customer response

  06/27/2022

  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,
  
  ***** ******
  
  There is nothing about Holly P******'s statement that is true. There was NO phone call on March 20th. We spoke with Natasha on March 28th. Natasha told us I was covered for the exam. More than once! Also, My wife NEVER told Natasha we had *** through *****. Another Medical Mutual rep discussed *** in a different phone call as I stated in an earlier response.
  It is clear that Medical Mutual is covering for the false information that we were given. Medical Mutual cannot even get their facts straight. There is one way to clear this all up. Let's listen to the recording form March 28th and the facts will be clear. Maybe we will have to listen to the tape in court since Medical Mutual is covering this up. Medical Mutual is quick to take our money, but they will not take resposibility. This is why the 1.7 rating out of 5 on BBB. We are not the only ones who see through their operation.

• Initial Complaint

  03/30/2022

  Complaint Type:

  Billing Issues

  Status:

  Resolved

  More info

  I have been promised action to have a billing issue addressed, just find delay after delay I have been told multiple dates that I would have the information and no one cares to respond, I as the consumer have had to call when dates and promises have failed to be kept, no one will take ownership of the problem, pass the problem on to someone else , maybe I will just give up, I will not give up, hopefully this will generate a response from someone who truly cares ***** *******

  Business response

  04/05/2022

  04/05/2022
  
  
  Dear Mr. *******:
  
  Medical Mutual appreciates your feedback and we are sorry to hear your experience has not been a positive one. We value our members and exceptional service is always our priority.
  
  I am writing to respond to the complaint forwarded from the Better Business Bureau on 03/31/2022.  Your complaint is regarding a billing issue not being resolved.
  
  On 03/17/2022, you requested an audit of your pharmacy claims for two years. We requested this from our pharmacy department
  
  On 03/23/2022, you called Medical Mutual and advised you are not receiving the request fast enough. We then sent a claims summary showing the breakdown of charges to you via email.  
  
  On 03/30/2022, you advised that what Medical Mutual sent was incorrect and that ******* ******** was inappropriately charging you and the copay assistance through OPUS is being billed incorrectly.
  
  On 03/31/2022, a Presidential Escalation representative along with a Billing Leadership Representative from ******* ******** conference called you regarding your complaint. The Billing Representative provided a breakdown of a credit on your account and discussed a refund. You then selected a paper check to be mailed to you. The Billing Leadership Representative ensured a follow up on your account, as well as to determine if ******* ******** needs to fill a refill of the medication or if you will be filling it externally.
  
  If you require additional assistance, please feel free to call ******* ******** and they welcome the opportunity to review this information with you.
  
  
  
  Sincerely,
  
  
  Holly P******
  Customer Resolution Specialist
  Appeal and Complaint Department
  
  

  Customer response

  04/05/2022

  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.
  
  The response is I expected from Medical Mutual Of Ohio has in accurate information

  1 On 03/17/2022 I did request invoices for ****** because of a discrepancy in an Invoice that I received from ******* as I had received a total of 4 invoices dated 03/16/2022 of which 3 are different , I asked for assistance from Medical Mutual of Ohio that I could not get correct information from ******* Specialty Pharmacy,

  2 I did in fact call Medical Mutual on Wednesday on or about 03/23/2022  because I was told by an Medical Mutual Of Ohio employee on  or about 03/17/2022 it would take between 24 to 48 hours for me to get the information . I did not receive a response on Tuesday which would have been over the 48 hours , I contacted Medical Mutual Of Ohio asking the status , I would have received a response by Medical Mutual Of Ohio's  " Customer Service" which they had failed to provide Customer Service, to a customer. I did receive an Email later from Lori D**** that did not help and did not include invoice I requested

  On or Around 03/25/2022 I received a Email and a phone call from Tiffney E****, she realized what she emailed me was not what i was looking for and said to disregard the Email, we spoke by phone and she said she would have a response later that day before 5 pm , I advised her she would not be successful in that time line , she stated she wanted to prove me wrong and would get back t me  at 5 pm. I did not receive that call I did however receive a call from a unknown number at 4.57pm Saturday 03/2022 and a message was left stating calling me back about the invoices( again notice her wording INVOICES)

    she would not be in the office Monday and work 1/2 day Tuesday and may be able to reach out on Tuesday, never received that call either. I responded back to Tiffney's Email and attached copies of the invoices I received from ******* ******** , she acknowledged receiving that Email

  3 The information I received on 03/30/2022 by E mail from Tiffney E**** at @ 5.54 pm was to be delivered and call back at 5PM per Tiffney's supervisor Nicole per phone discussion earlier that day, Again  un kept promise, No invoices were included I advised Tiffney the information was not what i asked for and was useless to me.

  4 I do not understand Medical Mutual Of Ohio being involved with my discussion with the escalation with ******* ******* Presidents Escalation Rep and ******* billing Rep , Medical Mutual Of Ohio has not shown interest assisting me from the beginning, As far as I am concerned that statement should not be included in their response, I do not recall giving any otherization for them to be involved with my issue with contacting Presidential Escalation and my dialog with them.

  
  

  Regards,

  
  ***** *******

  Business response

  04/07/2022

  Dear Mr. *******,
  
  Thank you for taking the time to speak with me today regarding your complaint. I understand your frustration on not getting the documents requested and your disappointment in not receiving returned calls at the times we advised we would. You ultimately took time out of your day to contact ******* yourself to get the issue resolved. We acknowledge that we could have done a better job of assisting you with that interaction. You indicated that no other information was needed from Medical Mutual at this time. Our Leadership team will review this complaint for potential training and coaching opportunities. We sincerely apologize for any inconvenience this has caused you.
  
  Sincerely,
  
  Holly P******
  Medical Mutual
  Customer Resolution Specialist

  Customer response

  04/07/2022

  [A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is not satisfactory been resolved, however I know that nothing more could resolve this for me , I asked the Medical Mutual rep to please help the next person not have to go through what they put me through,that would help me knowing someone else didn’t suffer like I did!
  
  Regards,
  
  ***** *******
  

• Initial Complaint

  01/25/2022

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  On June 6 of 2021, I visited the ********* Hospital Emergency Room (********* ******) because I had a sudden onset of crippling, throbbing pain in my neck that I had never experienced before. The pain left me unable to stand, and with radiating pain through one side of my upper body. Upon my admission to the ER, the attending physician ordered a CAT scan because he suspected a stroke. Medical Mutual denied this claim stating it was not a legitimate reason to visit the emergency room. Upon the recommendation of a Medical Mutual representative, I contacted the head of the emergency department at ********* Hospital to provide a letter of medical necessity to them Medical Mutual. The doctor assured me my visit was one of "medical necessity" and had the ********* ****** billing department provide the letter. Nevertheless, Medical Mutual denied the claim. When I spoke with a member of the Medical Mutual customer service team, I asked them, "If I have severe chest pains, and go to the emergency room because I am afraid of a heart attack, are you saying you would deny my claim and I would be responsible?" The representative said, "yes." For what it is worth she was extremely rude. I have filed an appeal through the Medical Mutual and am hoping for the best. This bill exceeds $3000. I would like for

  Business response

  01/31/2022

  01/31/2022
  
  Better Business Bureau
  200 Treeworth Blvd.
  Broadview Hts, OH 44147
  
  RE: **** *********
  Complaint ID ********
  
  To whom it may concern:
  
  Medical Mutual appreciates your feedback and we are sorry to hear your experience has not been a positive one. We value our members and exceptional service is always our priority.
  
  We received the claim for your visit to the Emergency Department which was denied as under the terms of this contract, emergency room charges that do not meet medical emergency or accident emergency criteria are not eligible for coverage.
  
  The provider appealed with emergency room records. The appeal was upheld as under this patient's coverage, benefits are available for emergency room treatment if the service is related to a medical emergency. The medical record information submitted does not indicate that this treatment was related to a medical emergency. Therefore, this claim has been processed based on the non-emergency provisions of the patient's contract.
  
  We received the internal member appeal on 01/25/2022, which is currently in process. You will receive a written response with the outcome within 30 days of the receipt date.
  
  Sincerely,
  
  Holly P******
  Customer Resolution Specialist
  Appeal and Complaint Department

• Initial Complaint

  01/17/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  My Father in Law had Medical Mutual and had paid his premiums in full. He passed away in July of 2021 and I filed for a refund so his wife could have the money left over. We had to go to the court and file for an Affidavit then fax all the paperwork to Medical Mutual and this was completed in August 2021. It is now January 17, 2022 and they have yet to send out the check. I have called numerous times and they tell me it will at my house within 2 weeks.

  Business response

  01/21/2022

  January 21, 2022
  
  
  Medical Mutual appreciates your feedback and we are sorry to hear your experience has not been a positive one. We value our members and exceptional service is always our priority. We are sorry to hear of the passing of your father in law. A representative from Medical Mutual reached out and left a detailed message on January 17, 2022, and additional calls on January 18, 2022 and January 21, 2022 to return our call, but we have not heard back from you.  
  
  Medical Mutual requires an ‘Affidavit of Person Claiming Refund due to a Deceased Member’ form to be completed and notarized, along with a copy of the death certificate, and a voided check. As of today, we have not received this documentation.
  
  To expedite the request, you may email the documents to Cashiers@medmutual.com.  I have attached the form for your records.
  
  
  Sincerely,
  
  Holly P******
  Customer Resolution Specialist

  Customer response

  01/22/2022

  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.
  
  The affadavit was faxed on  8/23/21.  I have talked to them 4 times since then and they have not once mentioned that they needed us to resend these papers until now.  On 11/12/21 they said they received the paperwork and that they would request the cashier dept to resend the check.  On 11/29/21 they said that the check should be here by the 2nd week of December.  

  No check as of 1/22/2021

  
  Regards,
  
  ***** *******
  

  Business response

  01/24/2022

  Good morning Ms. *******:

   

  Unfortunately, the notarized affidavit was not included in the fax to Medical Mutual and we cannot issue a refund into someone else's name without it. Medical Mutual requires an ‘Affidavit of Person Claiming Refund due to a Deceased Member’ form to be completed and notarized, along with a copy of the death certificate. We received a copy of the death certificate and we are now awaiting the affidavit to complete the request. If you would like the refund electronically deposited, please include a voided check. Otherwise, a paper check will be sent via USPS.  To expedite the request, you may email the documents to Cashiers@medmutual.com. 

   

  Sincerely,

   

  Holly P******

  Medical Mutual

  Customer Resolution Specialist

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