Oxford Healthcare / lack of reimbursement

1 Meeting House Lane, Southampton, NY, United States Review updated:

In March of 2011 I had surgery to repair a hernia. With the ever-changing status of which institutions had a contract with Oxford, I checked with Southampton Hospital (SHH) as to the coverage of the surgery. I was told they are a participating hospital, that the surgery and associated services would be covered and that I was responsible for my coinsurance. I knew the surgeon I elected to perform the surgery was out-of-network. I have no outstanding bills with the hospital or surgeon.

Months later I receive a bill from East End Anesthesiology (EEA) for the surgery. I wrote a letter to Oxford concerning this bill. When I did not receive a response I called. I was told that my letter did not state I wanted to ‘appeal’ and that by not using that specific word in my first letter, my question of the bill was not considered and that I was at the end of the time period allotted for appeals.

> EEA are the only anesthetists that work at the hospital.
> I had no choice in the matter.
> Anesthesia was mandatory for the surgery could not have been performed without this service.
> I was not informed of EEA's non-participating status.
> Oxford's appeal process is not member friendly and does not serve a valid purpose to protect single members who are paying more than $6000 per year for healthcare coverage.

What Oxford considers a ‘fair and honest appeal process’ is of no value if the Grievance Board does not consider a 33% ($2750) increase to my yearly healthcare bill unfair and outrageous.

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  • Mi
      27th of Sep, 2011
    Oxford Healthcare - Oxford did not pay provider
    Oxford Healthcare
    United States

    Oxford did not pay provider. Several calls were made and customer service did not note the calls. I was told numerous times that the claim forms were not received. I faxed the claims twice. The provider was still not paid. On one of the many attempts I was told that the claims were "put aside" and not processed. I was told that they would be processed. Oxford did not process the claim on time therefore 90 days had passed and the provider was not paid. I received a letter stating that they had come to a decision, that I was called and did not answer the phone. This was the reason I called today, to find out the outcome. I was told that they only reviewed the form and did not review the calls I had made. They did not check the system. They only checked the dates on the claim forms and decided not pay. I have never had trouble with health care providers in the past. I will be sure to post this on several sites. I would like to know who else has had problems with "lost" claim forms.

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