Multi-Plan PPO, Preferred Care, American Medical and Life Insurance Company / Insurance Fraud
March 8, 2010
American Medical and Life Insurance Company
c/o Fraud Special Investigation Unit
8 West 38th Street, Suite 1001
New York, New York
SUBJECT: Appeal Process
RE: Letter of grievance
I have never written a letter of grievance before but felt this matter should be addressed.
In mid-October, 2009, I called and spoke with Tom & Carol, insurance agents employed by First Choice [protected]. At that time I was seeking an individual medical insurance policy, because my Cobra policy would be ending on November 30, 2009. Having never had to seek insurance on my own before, I was open to any suggestions. November 1, 2009 was designated as my insurance sign-up deadline, since it would take two weeks for processing to go through and a routine colonoscopy had been scheduled for November 5, 2009.
My main concern, with the impending colonoscopy, was that my new policy would cover this procedure. Both Tom and Carol presented the benefits of belonging to a “group policy” rather than an individual policy and suggested NAPA (National Association of Political Advocacy – Multi-Plan PPO). I further checked with them regarding both Adventist Hinsdale Hospital and Hinsdale Gastroenterology Associates (Dr. Seraphin) since I was having the colonoscopy done at Adventist Hinsdale Hospital and performed by Dr. Seraphin. After checking into the colonoscopy coverage, Tom called me back and told me that all were within the Multi-Plan Network. At that time I was also told that both IN-PATIENT and OUT-PATIENT procedures were covered in this policy (80-20).
One of the first stipulations was that I had to become a member of NAPA, with a yearly membership fee of $130.00 in addition to paying the first month’s payment $229.00 immediately – before paperwork of any kind could begin. With the November 1, 2009 deadline approaching, I agreed. To this date I have never received a copy of my policy. I did receive a “Member Programs” booklet which in no way defines what is covered or not covered in this policy.
I went in for colonoscopy as scheduled and Dr. Seraphin, DO, performed this routine colonoscopy. During this 15 minute local procedure a 6mm sessile polyp was removed as a preventative measure. I was told by Dr. Seraphin’s office that this minor polyp removal is performed routinely 9 out of 10 times a colonoscopy is performed. This removal is a preventative procedure and eliminates the potential problem at a later date. While in recovery, I was told all had gone well and it would not be necessary to have another colonoscopy for 5 years.
On November 19, 2009, I received the billing from Hinsdale Gastroenterology Associates and learned that when they submitted my claim to NAPA-Multi-Plan it was denied due to the removal of the polyp, stipulating that any surgical procedure (which is what they are calling this minor polyp removal) requires a LICENSED ANESTHESIOLOGIST.
Contacting Hinsdale Gastroenterology Associates they informed me that a LICENSED ANESTHESIOLOGIST has never been required for this 15 minute (local) procedure to be covered by an insurance carrier. Either a routine colonoscopy is or is not a covered procedure. Judy (billing specialist) at Dr. Seraphin’s office stated that in her 20 years she has never heard of a denial to pay a claim for this reason and in 9 out of 10 times a polyp is found and removed.
Seeing the injustice and since I am not familiar with codes and such, Judy from Hinsdale Gastroenterology Associates, called to speak with someone in Claims at Multi-Plan [protected]). Additionally she spoke with Christina in Benefits [protected] and explained she does all billing for Dr. Seraphin and has NEVER encountered this request for a LICENSED ANESTHESIOLOGIST. Per Judy -- it is not feasible to do a colonoscopy – note a small polyp during the procedure – wait while the patient revives from the local – line up a surgical room – get a LICENSED ANESTHESIOLOGIST, take the patient into a surgical room and perform the procedure once again.
Over her 20 years of billing for this doctor, she has dealt with many insurance carriers (including Medicare) and has never come across a stipulation of this type in this routine procedure.
After Judy spoke to Christina in Benefits [protected] (Case #2987273) she called me back and told me that she had told her that my policy was “VERY LIMITED”; yet no one ever mentioned policy limitations/stipulations -- even after I questioned if the colonoscopy was a covered procedure.
Additionally Judy learned that my policy does not cover Outpatient Surgeries, nor is Adventist Hinsdale Hospital in the Network; therefore they were billing me additionally for out of Network charges.
I looked online to verify that Adventist Hinsdale Hospital was in the Network and called Christina back after I learned it was. She then told me Multi-Plan had stopped their IN-Network with Adventist Hinsdale Hospital five years earlier and apparently someone must have neglected to remove them from the online list of available hospitals. I contacted Provider Relations and was told that I needed to contact Provider Education about this situation [protected], and Case number 2987044 was issued. They told me to ask for an OPEN BALANCE BILLING.
Calling Multi-Plain [protected] as instructed, I spoke with James M (agent) and he spoke with a Steven – team leader – telling me that he would so note the error and that the mistake would be corrected in two weeks. He suggested that I call again in two weeks to verify that it had been taken care of.
This simple procedure has turned into a very complicated situation. Being unemployed makes this non-covered procedure even more stressful. Please review this case and check into how often a LICENSED ANESTHESIOLOGIST is used during this routine procedure, which is done on hundreds of individuals daily. The cost of retaining a LICENSED ANESTHESIOLOGIST would sky rocket the cost of this simple procedure and make it cost prohibitive. Please let me know your thoughts on this situation. May I also ask that someone send a copy of my policy (Silver Plan 500) to the address listed below.
Member ID: NCE9400935
620 68th Street
Willowbrook, IL 60527
John Ollis, President & Chief Executive Officer,
Walt Boraczek, Vice President, Operations and Technology
Tina Butler, Director of Client Services
Lorraine Classi, Executive Vice President
Michael James, Executive Vice President & General Counsel
Scott McGregor, CPA, CFA, D.P.S., Exec. V.P. & Chief Financial Officer
Steve Mellas, Chief Compliance Officer
Robert Ostrander, Executive Vice President, Chief Underwriting Officer
Chris W & Sharen G – Supervisor-amli-PO Box 1235, Frederick, MD [protected]
All Executive Officers at:
Corporate Quality Management
MultiPlan - Corporate Quality Management Department
1100 Winter Street
Waltham, MA 02451
115 Fifth Avenue
New York, NY 10003
Channel 2 Newsroom-Chicago-Pam Zekman
Illinois Department of Insurance
Attorney General-Lisa Madigan’s Office-Health Care Bureau