ComplaintsforCommon Ground Healthcare Cooperative

• Initial Complaint

  12/02/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  On November 21, 2023, my eye doctor submitted a request for a prescription called Tyrvaya for Keratoconjunctivitis- Sicca (Dry eye) which I have had for several years. Previously, I was on Restasis .05 eye emulsion which no longer works. Common Ground denied this claim after sitting on a prior authorization since 11-23-23. The rejection letter stated I need to try Cequa, and the above medication doesnt fit Optum RX drug coverage policy. My Dr. ********* an RX on 12-1-23 for Cequa, (the medication suggested I needed to try first by Common Ground Insurance in their denial letter!) I went to to pickup at pharmacy on 12-2-23. Once again, Common Ground is denying this prescription demanding a prior authorization for my prescription stating I need a PA. I have met my Out of pocket for the year and I believe Common Ground is playing this game because it is an expensive prescription and are delaying until 12-31-23so they dont have to provide this drug under my plan. Due to the PA game Common ground plays I have been denied critical eye care since 11-23-23! I want, and need this prescription and unfortunately I have this crummy insurance who loves to play the denial game. If this game of denial, by Common Ground and OptumRx impedes the healing after my cataract surgery and the result is my loss of my eye sight there maybe a lawsuit pending.

  Business response

  12/11/2023

  12/11/2023
  *********************
  BBB of *********
  **************************************************************************************************
  File Number: 20949739
  Complainant: *****************************
  Dear ******************,
  We appreciate the opportunity to address the concerns raised by the complainant in connection with their
  experience with our organization.
  Due to the sensitive nature of the matter and our commitment to uphold the privacy rights afforded by
  HIPAA laws, we are constrained in providing extensive details in this response. However, we want to
  assure the BBB and the complainant that we take all concerns seriously and have thoroughly investigated
  the matter.
  After conducting an internal review, we are pleased to inform you that we have successfully resolved the
  complaint in question. The resolution was implemented on 12/6/2023. To keep the complainant
  informed, a written correspondence outlining the resolution details was dispatched via mail on
  12/7/2023. Furthermore, the member was contacted via phone on 12/8/2023.
  We appreciate your understanding of the privacy limitations imposed by HIPAA, and we thank the BBB for
  facilitating a platform for communication and resolution. Our commitment to customer satisfaction and
  compliance remains steadfast, and we are confident that the complainant is now satisfied with the
  resolution.
  Thank you for your attention to this matter.
  We hope this helps to resolve the complaint. If you need further assistance, please contact me by email
  at ************************************************************************** or phone ************.
  Sincerely,
  Common Ground Healthcare Cooperative

  Customer response

  12/11/2023

  [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 satisfactory to me. 
  
  Regards,
  
  *****************************
  

• Initial Complaint

  07/30/2023

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  On July 11, I spoke with ***** in Customer Service/ and ******* in claims regarding out of pocket expenses since my accumulations on total bills at Common Ground was at $5,866.28 YTD. My max out-of-pocket expenses for 2023 is $7500. I have 3 outstanding bills; $2,253.33 for an MRI at ***** Care, Radiology and associates for $305.28, and Hand to Shoulder for $486.34 which would put my out of pocket expense at $8,424.89 which is $924.89 over my total! I won't pay vendors more than my out of pocket since I would need to chase the money. Common Ground gets their monthly premium to manage the system, which they failed for ***** I sent 4 Emails and several calls (another on 7-28-23 spoke with *******) again requesting requesting my accumulation report - never received a mailed copy.I paid bills as I received them from healthcare providers. If vendors negotiate lower rates with Common Ground and I was to have been charged a lower rate - I am not aware of what those discounts are since CG didn't specify a lower payment. I have Common Ground Insurance Bronze package in which the insurance pays nothing on my behalf until I have met my out of pocket expense. If vendors negotiate a lower rate that I am to pay - the bills should reflect the discounted rate - since CG doesn't share those totals.I am filing this complaint since all 3 vendors are threatening to send me to collections and I will not allow CG to ruin my credit. Common Ground needs to reprocess these outstanding bills.

  Business response

  08/09/2023

  We are writing in response to the complaint received from the Better Business Bureau on 7/30/2023.
  Upon review of the information provided, CGHC reached the following conclusions based upon our
  investigation.
  The member's claims have all been processed correctly according to her plan benefits. She did not reach
  her out-of-pocket maximum until early August, which was after this complaint was received. In addition,
  the member stated CGHC did not supply the accumulation report to her; however, we sent it to her via
  email and/or mail to the mailing address and email address we have on file. We sent those
  communications to her on 7/12, 7/21, 7/27, 7/28, and 7/31. As a result of this complaint, CGHC has
  furnished the member with a copy of the accumulator report and explanations of benefits for all of the
  claims in question in writing to the address we have on file.

  Customer response

  08/11/2023

  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.  Attached are the accumulation report from CG website run on 7-31-23 where CG states I owe $9,382.34.  Also, my oop expenses paid YTD.
  On July 11, I spoke with ***** in Customer Service/ and ******* in claims regarding out of pocket expenses since my accumulations on total bills at Common Ground was at $5,866.28 YTD. My max out-of-pocket expenses for 2023 is $7500. I have 1 outstanding bill for $2,253.33 for an MRI at ***** Care, this puts my out of pocket total at $8380.99. I won't pay vendors more than my out of pocket since I would need to chase the money. Common Ground gets their monthly premium to manage the system, which they failed for 2023. I sent 4 Emails and several calls (another on 7-28-23 spoke with *******) again requesting my accumulation report - never received a mailed copy until 8-1-23.  This was after I met with ******************************* my insurance agent had a conversation with April ****** at CG on 7-31-23.  ***** stated an audit would be completed since the report on CG website total showed I owed was $9,382.34. I paid bills as I received them from healthcare providers. If vendors negotiate lower rates with Common Ground and I was to have been charged a lower rate - I am not aware of what those discounts are since CG didn't specify a lower payment. I have Common Ground Insurance Bronze package in which the insurance pays nothing on my behalf until I have met my out of pocket expense. If vendors negotiate a lower rate that I am to pay - the bills should reflect the discounted rate - since CG doesn't share those totals. I am filing this complaint since i am being threatening to send me to collections and I will not allow CG to ruin my credit. Common Ground needs to reprocess this outstanding bill.  On 8-10-23 I spoke with ***** in claims who stated the attached report from their website wasn't accurate and I should trust their accuracy even though they have not been helpful through this process.  I will file a complaint with the *********************** since CG is unreasonable.  Next will be senators'! 
  
  
  
  Regards,
  
  *****************************

  Business response

  08/28/2023

  We are writing in response to the complaint received from the Better Business Bureau on
  7/30/2023. Upon review of the information provided, Common Ground Healthcare Cooperative
  (CGHC) reached the following conclusions based upon our investigation.
  Incorrect Accumulator Report: ************************ assertion regarding the accumulator report
  received on August 1, 2023, is correct. The report indicated a debt of $9,382.34; However, this
  report was not accurate nor the most current report. On August 9, 2023, CGHC mailed a
  current accumulator report communication to ********************, concurrent with the submission
  of information to the Better Business Bureau.
  Provider Discounts: Every Explanation of Benefits (EOB) that CGHC sends to members includes the
  submitted charges from the provider, as well as the allowed amount based on the discounts CGHC
  obtains from in-network providers. The EOBs that ******************** has received on all of her claims
  includes this information.
  Reprocessing of the Claim: CGHC will not reprocess the claim in question. ******************** owes that
  amount as she had not met her out-of-pocket maximum at that time. She successfully reached
  that threshold on July 2, 2023, which is after the date of service in question.
  We hope this helps to resolve the complaint. If you need further assistance, please contact me by
  email at ************************************************************************** or phone ************.
  Sincerely,
  Common Ground Healthcare Cooperative

  Customer response

  08/28/2023

  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 Common ground did not assist in procuring the lowest amount I am to pay out of pocket amount.  Resulting in my paying over the $7500 out of pocket.  ThedaCare is working with me regarding a lower, reasonable price.  Since this will be a public document, I urge anyone considering Common

  Ground for insurance should reconsider.  They do nothing and delay procedures in hopes they dont have to pay!
  
  Regards,
  
  *****************************

  Business response

  08/30/2023

  August 30, 2023
  *************************
  BBB of *********
  **************************************************************************************************
  File Number: 20396975
  Complainant: *****************************
  Dear ********************,
  We understand ******************** remains dissatisfied; however, we processed all of her claims according
  to her plan benefits. As a result, our position has not changed. We have provided ******************** with
  a detailed report of what claims applied to her out-of-pocket maximum, as well as the detailed
  Explanation of Benefits that show the discounts she received from her in-network providers. Ms.
  ******** also submitted a complaint to the ********* *************************************** (OCI)
  that we are responding to with all of the same details. She will receive a response from OCI related to
  her complaint in the coming weeks. We have no additional information to offer at this time, and we
  consider this matter closed.
  Sincerely,
  Common Ground Healthcare Cooperative

  Customer response

  08/31/2023

  Better Business Bureau:
  8-31-23
  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.
  
  On July 11, 2023 I spoke with ***** in Customer Service/ and ******* in claims regarding my out of pocket expenses since my accumulations on total bills paid from Common was at $5,866.28. According to the accumulation report from CG I met my OOP on 7-2-23, yet no notification from CG that I met my oop. My out-of-pocket expenses for 2023 is $7500.  My oop paid amount for 2023 is at $7,226.68. I have 1 outstanding bill  for $2,253.33 for an MRI through ***** Care this would put my out of pocket at $9,480.00.  which is $1980.00 over my total oop. I am not paying over my $7500.00 as I know I wont get reimbursed by vendors who were over paid.
  I sent 4 Emails and several calls (another on 7-28-23 spoke with *******) again requesting my accumulation report.  It was sent via email, even though I requested a mailed copy   I received the accumulation report in the mail after I filed a complaint with the BBB. Yet CG takes my premium payment every month. 
  I paid bills as I received them from healthcare providers.  If vendors negotiate lower rates with Common Ground and I was to have been charged a lower rate - I am not aware of what those discounts are since CG didn't specify a lower payment or how to pay according to assigned discounts.
  I have attached my accumulation report because it is impossible to cross reference their report to mine.
  since ***** Care is threatening to send me to collections, I will not allow CG to ruin my credit. Since Several attempts were made to resolve this through Common Ground with no assistance, I filed this complaint along with a complaint to the **********************. The accumulation report downloaded from CG website shows a total of $9,382.34 total oop.  *****, my insurance agent downloaded the attached excel spreadsheet on 7-31-23 from CG website.
  Common Ground is not assisting in the over charges.  That is the least they can do since they did nothing on my behalf since 1-1-23!
  
  Regards,
  
  *****************************

• Initial Complaint

  03/15/2023

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  Hello~During Open Enrollment 2022, I enrolled in a Common Ground on-Market plan for 2023. On December 30th, 2022, I paid my insurance invoice online for ******** and I selected the option for autopay for future months. The January premium was processed when I checked my credit card statement, so I believed everything was set. On March 9th, I uploaded my required identity proofs to the Marketplace via HealthSherpa. I notified my broker, *************************** (NPN ********), of the upload. ***** then checked on her broker portal to confirm the upload was received and found that my insurance showed as terminated as of March 9th. ***** was concerned that a technical error occurred as I uploaded documents, so she investigated and found that Common Ground had cancelled my insurance on March 2nd back to January 31st for nonpayment of premium. We were both confused, I had set up autopay. I had not received a grace ****** notice. I submitted (via *****) a request for reinstatement to Common Ground. Common Ground denied my request, stating they had sent a grace ****** notice and an invoice. I did not receive the grace ****** notice, though I did find the bill today lumped in with my mother's mail. Regardless, I was confident I was set up for autopay and they do send copies of the bills when someone is on autopay. I set up autopay in good faith and I believe this issue was caused wholly by an error within the Common Ground payment system. As Common Ground has been unwilling to act in good faith and reinstate me, I ask the Better Business Bureau to intervene. I am fully willing to pay all premiums owed. I give my permission for the BBB to contact or share information with my broker *************************** as well, ***** can be reached at *************** or ************. Sincerely, *************************

  Business response

  03/23/2023

  Please see the attached that includes our response to this complaint. If you have any questions, please contact me at your earliest convenience. Thank you, ******************

  We are writing in response to the complaint received from the Better Business Bureau on 3/15/2023, on behalf of CGHC member, **********************  **************** is asking Common Ground Healthcare Cooperative (CGHC) to reinstate their CGHC policy and allow him to make a late premium payment for February, 2023 and is willing to make payments onward.   In the complaint, **************** indicated that during 2022 Open Enrollment, he enrolled with CGHC through the Marketplace for 2023. He indicated he paid the invoice for ******* online and selected the option to autopay for future months. He found out from his broker that his CGHC coverage was terminated on ******* 31, 2023, for non-payment of premiums. The member stated they submitted a request to CGHC to ask for a reinstatement, but the request was denied and was advised that an invoice and a grace ****** notice was mailed.Member indicated that he did not receive the grace ****** notice, however he did find the invoice with his mothers mail. **************** indicated he set up autopay in good faith and believes that this issue was caused by an error with CGHC payment system.  Upon review of the information provided, CGHC reached the following conclusions based upon our investigation:? 12/12/2022 ********************* enrolled with CGHC Copay Bronze $0 Ded - Envision Network, effective 1/1/2023, through the Federally Facilitated Marketplace.? 12/30/2023 Member made premium payment to effectuate coverage from 1/1/23 through 1/31/2023.? 1/4/2023 CGHC mailed the member an invoice for February coverage, indicating payment was due 1/25/23.? 2/1/2023 CGHC did not receive the February premium payment, so we mailed the member a Grace ****** advising the member that we have not received the premium payment for February coverage that was due on 1/25/23.? 2/3/2023 CGHC mailed a March invoice with the balance reflecting payment due for February and March 2023 coverage.? 3/1/2023 CGHC terminated the member effective 1/31/2023, for non-payment of premiums as no payment has been made since 12/30/2022.? 3/15/2023 CGHC received the Better Business Bureau complaint.? 3/22/2023 Investigation of case revealed that there are no calls from the member or from the broker regarding this complaint.? 3/22/2023 Investigation of auto-payments selected revealed that we have received a one-time payment from *************** and it does not appear that auto-pay was selected (see enclosed snapshot).? 3/22/2023 Investigation also showsthat we mailed all correspondence to the following address below which appears to be the same address listed in the BBB complaint.**************************************************************** We are sorry that this member lost his coverage with CGHC due to non-payment of premiums.  However, we did make every effort to notify **************** about making his premium payments to continue his healthcare coverage.Unfortunately, at this time CGHC cannot accept the late premium payment for February and allow payment for future coverage. We made this decision to ensure it is appropriate and equitable for our entire membership.We hope this helps to resolve the complaint. If you need further assistance, please contact me by email at ************************************************************************** or phone ************.

  Customer response

  03/24/2023

  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.
  
  I never received a ***** notice and I signed up for autopay, I should not be penalized or rejected simply based on Common Grounds autopay system failing. I attest I signed up for autopay. I request reinstatement on grounds of system error, which is an allowable carrier reinstatement reason regarding Marketplace plans. 
  
  Regards,
  
  *********************

  Business response

  04/03/2023

  Please see the attached letter that includes Common Ground Healthcare Cooperative's response to the complaint. Any questions, please contact me at your earliest convenience. 

  We are writing in response to the additional complaint received from the Better Business Bureau on 3/27/2023. In that complaint Mr. ********************* indicated he never received the ***** notice, he attested to signing up for autopay, he does not believe he should be penalized for CGHCs autopay system failing, and he is requesting reinstatement of his health insurance policy. CGHC has reviewed the additional comments and request. However, we regret to inform **************** that CGHCs decision remains the same to deny reinstatement of coverage due to non-payment of premium, which was made based upon the facts outlined in the outcome letter as well as the rules outlined in the Certificate of Coverage (see enclosures). We hope this helps to resolve the complaint. If you need further assistance, please contact me by email at ************************************************************************** or phone ************

  Customer response

  04/03/2023

  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.
  
  I recognize that Common Ground will not budge, and as it is impossible to prove I set up autopay or did not receive a notice of ***** period, there appears to be nothing more to do other than voice my dissatisfaction with Common Ground's decision. Therefore, the complaint may be closed but it is not resolved. 
  
  Regards,
  
  *********************

• Initial Complaint

  01/27/2023

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  During open enrollment with the Healthcare Marketplace, I selected a policy offered by Common Ground Healthcare Cooperative (CGHC) but was initially denied the Healthcare Tax Credit. I paid the full policy premium due for ******* of $916.49 while I appealed for the tax credit because I can ill afford to be uninsured. I filed an appeal since my income was less than 2022 when I qualified. Within a few days, I was notified that my appeal for that tax credit had been approved. I contacted CGHC to let them know and their customer service person told me that once the funds had been received, I should call back about the reimbursement of my funds. When I checked again to see my account balance, I saw that Common Ground Healthcare Cooperative recieved $848 from the Healthcare Tax Credit applied to my account, and so I called to request that the difference ($774.66) be applied for the month of February ($141.83), and that they reimburse me the $632.83 difference. They told me that their policy is to hold my funds as a credit toward my future payments. It apparently is their policy to hold their customer's funds until they run out and apply them to each month's premium. That means they are holding my funds for the next 4 months, denying me the opportunity to collect interest. I objected to the policy and their customer service representative said they would submit an appeal on my behalf and I could expect to recieve a response in 12 to 14 days. As a member of a cooperative, I object to this policy since I am being denied access to the use of my own funds for purposes of my own choice, and these seem like delay tactics so they can use my funds and I cannot during the next months. Given that I'm living on a small pensioner's income and need those funds to pay other bills, so I find their policy of holding my funds a financial hardship in the short term. This policy seems inconsistent with the mission of a cooperative and to create unnecessary delay and paperwork.

  Business response

  01/31/2023

  Dear *************************,

   

  Thank you for contacting Common Ground Healthcare Cooperative regarding complaint 18937366, received by you on 1/27/2023. Our records show that the customer was issued a refund of the referenced amount on 1/26/2023. Please let us know if the customer has additional questions or needs further assistance.

   

  Thank you,

  *************************

  Manager of Member Experience

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩