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Multi-Plan PPO, Preferred Care, American Medical and Life Insurance Company / Insurance Fraud

1 2000 W. Commercial Blvd #100BFt Lauderdale, FL, United States Review updated:
Contact information:
Phone: 800-688-5167 X7187

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.

Respectfully,
Lori Vollbrecht
Member ID: NCE9400935
Group #NCE04
620 68th Street
Willowbrook, IL 60527

Cc:
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

MultiPlan, Inc.
115 Fifth Avenue
New York, NY 10003
Phone: [protected]
Fax: [protected]

Cc: Oprah.com
Channel 2 Newsroom-Chicago-Pam Zekman
Illinois Department of Insurance
Attorney General-Lisa Madigan’s Office-Health Care Bureau
Chicago Tribune

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Comments

  • Bu
      17th of Mar, 2010
    0 Votes

    She should contact the department of insurance in the state she lives in. They have rules about advertising, company and/or agent/agency. She should capture the web page before they remove the providers from their in network listing.

  • Kn
      29th of Mar, 2010
    0 Votes

    Multiplan is just a network of healthcare providers just like BeechStrret of Galaxy Health. It (Multiplan) IS NOT an insurance company or insurance plan.

    Insurability is the issue here and whether or not it is prudent to come off of COBRA when an uninsurable issue exists.

    The plan underwritten by AMLI is the same plan previous marketed by Cinergy health. There is a class action lawsuit against Cinergy and AMLI. The plan has limited benefits since the applicant cannot/does not qualify for major medical insurance. An insured should ALWAYS stay on COBRA if he/she can afford to if saddled with pre-existing health conditions. If one must cancel due to finances a plan like this provides some limited benefits instead of NO benefits.

    Even though the healthcare bill addresses this it doesn't come into play until 2014 when pre-existing health conditions cease to be a bar to major medical health insurance. However, I expect the cost will be out of reach for the majority of people in this category. HOW DO WE PAY FOR IT? If you don't have it you will be fined...by the IRS. What a great idea...NOT!!! Even one day, one minute of the IRS in your life is way too long. Thanks Obama

  • Km
      19th of Jun, 2010
    0 Votes

    I have been making calls ALL day about this. We received a call in January 2010 that IIM would be taking over our AMLI coverage. Luckily, I hadn't made a doctor's visit since then. I received the packet from IIM today & my suspicions went up because there were aout 3 different "insurance providers" listed in the packet. I received no ID cards as they had promised so I started calling around. I called Phoenix Insurance Company & they said Frank Karns (supposedly the CEO) is just slapping their name on the cards and that they don't even do healthcare. I then called AMLI who said I was only covered for 6 months out of the whole time I have been paying. They said that in January, AIM cancelled their partnership with them. As I continued calling EVERY NUMBER I could get my hands on, none of them worked. I finally found a old card of mine with a website which had a number. I called the number & it redirected me to a man's personal cell phone. When I explained why I was calling, he said he gets these calls everyday. He said they took over his company using all of their information and were able to do so because they called it Association OF Independent managers instead of the real company Association FOR Independent managers. He said they FBI has been made aware of what is going on and that there will probably be no money ever seen by all of us who were scammed because the governmet is now involved. The two men doing this, Frak Karns and his partner have done the same thing to CEO Club and NOVA. Apparently the transactions are being taken out by IRG in NY but nobody can seem to find these men. I called the FL. Dept. of Insurance and they basically told me they couldn't do anything because there is no license anywhere in the country to look up. Thousands of dollars down the drain & nobody will do anything...PATHETIC!

  • Ga
      17th of Apr, 2012
    -1 Votes

    i need a health cover because i have colorectal cancer an agent called me and offer me the multi plan ppo but am afraid if this is an scam, he wants369 per month and tells that i will covered for all my needs, sure i purchase this thing called multiplan ppo, ??please give some clues.om my yaho, , hotgabe48@yahoo.com or here!!thank you truly, gabe!!

  • Sb
      23rd of Jul, 2014
    0 Votes

    My COBRA is ending very soon, and I am totally confused about which plan to go on. Multi-plan is trying to get me to
    give him a payment on the phone before I receive anything from him. I do not feel comfortable do this. The coverage sounds too good to be true.

  • Ha
      30th of Mar, 2017
    0 Votes

    My husband almost got scammed today. He called me at work to ask questions about Multi-Group Insurance Companies. He said he had found an affordable plan, they need a payment today and that they would email him the policy after he signed up. I told him NO F-ING WAY! Under no circumstances will he sign up until they send the policy and coverage in writing for us to review. No credit card information was exchanged, thank gosh but they sold his telephone number to several providers and now those providers are calling my husband. I then got on-line to google the company and found several complaints. They all sounded like the telephone call my husband just received from one of the minions at Multi Group telemarketing centers. Please people, be smart. Don't ever give a credit card or social until you have had a chance to review the terms and conditions of the contract you are entering into. Be especially wary if they are rushing you to make a now decision. If they want to make the sale, they can wait for you to do your research and happily send you information in writing, immediately. This joke of a company prays on Americans trying to obtain coverage. This is not a major medical plan. I am disgusted!!! High School Teacher. HK

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