POMCO Group / Inconsistent information - Wrongly declining claims
Last year, my new doctor's staff called to verify my benefits with POMCO. They were told nothing else besides my co-pay amount. Now, after 13 months - and after having received no explanations of benefits - POMCO has paid nothing on any of the claims that have been submitted. I've called repeatedly to find out what the problem is. I finally left a message stating that I was seeking a civil rights attorney and invoking my rights under the Patients Bill of Rights. I got a phone call...
The POMCO rep said that they told my doctor's office they needed to pre-authorize my visits because this provider is out-of-network. There are no qualified in-network providers who are familiar with my conditions; my doctor was highly-recommended and specializes in my problems, so in-network doctors were just not an option here. The thing is, my doctor's office still has a record of the call they made to POMCO detailing that nothing was said about pre-authorizing my visits/care - and that all they were told was my co-pay amount. The POMCO reps are so snide and condescending! The rep told me I "need to choose a network physician" - which is none of their business! They are interfering with my plan of care, and that is a violation of the Patient Bill of Rights!
I also had surgery last summer - and the hospital & doctor WERE in the POMCO provider network. They pre-certified. Everything should have been fine. However, POMCO has not paid the bill - and has failed to give any explanation for the lapse. I am also getting calls galore from places I've been sent for labwork and MRIs... and yes, those were in-network and calls were made to pre-authorize/verify coverage. But POMCO has not paid these claims!
They never sent me any plan booklet explaining the coverage. I had to beg to get a provider directory. Even though I didn't have those, these unpaid claims are not related to any lapse on my end - because the communication was between POMCO and the providers. I know all these providers aren't wrong. The common denominator here - is POMCO! It doesn't matter evidently if a provider is in their network... they'll still reject the claim!
My doctor's office informed me last week that my balance is so high that they're going to have to stop providing treatment. The problem is, I have several chronic problems and a permanent injury that is deteriorating - and if I miss one month of treatment from this doctor, I am confined to bed and very sick. I am permanently disabled.
POMCO is essentially causing my medical treatment to be interrupted because of their poor communication, disorganization and cold, uncaring representatives who are not helpful - but rather, hateful. Only one POMCO representative has been nice - when I can get her on the phone. I was told that this particular plan was not rolled out well at all, it was a real mess and it is very disorganized. That was a shock to hear, but as time went by, I understood what the representative meant by that!
I am being hounded by these providers who want me to pay what POMCO was supposed to pay. POMCO does not want me to contest these unpaid claims, but I'm not backing down. They've gotten nasty with me and just want me to go away. I've never had service THIS BAD!
For those who may be experiencing a similar situation, here is the Patients Bill of Rights:
1. Information Disclosure. Consumers have the right to receive accurate, easily understood information and some require assistance in making informed health care decisions about their health plans, professionals, and facilities.
2. Choice of Providers and Plans. Consumers have the right to a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care.
3. Access to Emergency Services. Consumers have the right to access emergency health care services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity -- including severe pain -- such that a "prudent layperson" could reasonably expect the absence of medical attention to result in placing that consumer's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
4. Participation in Treatment Decisions. Consumers have the right and responsibility to fully participate in all decisions related to their health care. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators.
5. Respect and Nondiscrimination. Consumers have the right to considerate, respectful care from all members of the health care system at all times and under all circumstances. An environment of mutual respect is essential to maintain a quality health care system.
6. Confidentiality of Health Information. Consumers have the right to communicate with health care providers in confidence and to have the confidentiality of their individually identifiable health care information protected. Consumers also have the right to review and copy their own medical records and request amendments to their records.
7. Complaints and Appeals. All consumers have the right to a fair and efficient process for resolving differences with their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review.
8. Consumer Responsibilities. In a health care system that protects consumers' rights, it is reasonable to expect and encourage consumers to assume reasonable responsibilities. Greater individual involvement by consumers in their care increases the likelihood of achieving the best outcomes and helps support a quality improvement, cost-conscious environment.
Wish me luck! This is very stressful and is making my health problems worse! If I lose this doctor, I may as well die.