The complaint has been investigated and
resolved to the customer's satisfactionResolved Today's Options/American Progressive Life Insurance Company of New York — Impossible resolution of problems
resolved to the customer's satisfaction
Today’s Options 9/11/2008
4888 Loop Central Drive
Houston, Texas 77081
To whom it may concern,
Please consider this letter as an official written complaint.
Assuming this company has someone concerned, I decided to write this letter as recent attempts to try to resolve issues with your claims issuer and your customer service representatives have failed.
First, it is very difficult to understand most of your representatives due to their accent, I have had to hang-up multiple times because I could not understand them. I have no hearing impairment. I am also not a racist.
Second, the representatives are normally not well trained and therefore incapable of giving a customer an accurate or true response.
Third, they apologize so often it becomes maddening. Apologies may be warranted, but they must be sincere. After calling about the same things over and over and getting no resolution or satisfaction to the same type of problem, it shows the apologies are not meant, but said to appease someone.
Fourth, they promise to call back the same day or the next day with an answer to your question or problem, but never do. The most recent example occurred 8/28/2008 when I called a female representative who said her name was Gem, After she was unable to give me a satisfactory answer, she put me on hold and came back to the phone and began giving me another explanation, which was being spoken by another person at her side. Again, there was no resolution, so she promised she would call me later in the day, or the next day at the latest. I told her I had been told this in the past numerous times and no one had done so. I knew she was not going to call back as she stated. This is the method your representatives are told by their co-worker or supervisor to enable them to end your contact with them.
Fifth, I have called your various customer representatives, advising of service dates, for which, I have received services and bills from the providers, but I have never received Explanation Of Benefits, (I refer as EOB or EOB’s following). You apparently have replaced EOB with claim recently. When I discuss a matter, I receive the cursory apology and then usually it ends with them telling me they will have to send the information to Houston for resolution. Again this is another way of just getting rid of the customer. As an example, I have written to your Houston office asking for the EOB’s I haven’t received, but never have I received them. I have also written them requesting an accounting or statement indicating a list of co-pays or coinsurance amounts, I have incurred in 2006 and 2007. Again no response from Houston.
Sixth, is the way your claim information, rarely matches the bill from the provider. It was very difficult to match up your EOB with the corresponding bill I had from the provider, because your amounts were different from what was stated on the provider’s bill. As a result, I have spent many hours compiling spreadsheets reflecting every bill I have received with each EOB I have received from you. As an example, an itemized statement from St. Joseph’s Hospital Health Center, in Syracuse, for an inpatient stay 7/19 to 7/28 in 2006. The itemized bill from the hospital totaled $63, 341.22, but your EOB #[protected] dated 8/30/2006, indicated the total charge was only $8, 330.00 with a $150.00 co-pay and a payment amount of $24, 709.99. Quite honestly, I found this very confusing to say the least. How can this information be correct? Obviously there is a problem. I am deeply concerned about the way your people do business and question if what you are reporting to Medicare is accurate. I also would like to know how your people check and verify the accuracy of the itemized statements. This particular statement for account #[protected] contains multiple entries for code 4019155, Accucheck @ $23.00 each. A total of 65 Accuchecks are billed for the time period. Page 5 indicates 21 Accuchecks were performed on 7/22/2006. Page 6 indicates 14 Accuchecks on 7/23/2006 and 14 Accuchecks on 7/24/2006. As I believe you know, an Accucheck is a test for determining your glucose level in your blood. Which requires [censored]ing your finger with a needle to get a blood sample to apply to a glucose strip. I can assure you, I would never let anyone perform this act on me 14 times on two days or 21 times in one day. I realize the actual cost paid is small in comparison to the billing price. My point is the accuracy of the billing and if anyone is finding errors like this. Is it fraud? Is it just an honest mistake? Did you confront the provider concerning these ridiculous entries? What did you report to Medicare for reimbursement or payment? I did question the hospital, but was told not to worry about it because adjustments were always made back and forth. I doubt the veracity in what I was told. What charge was submitted to Medicare by your company?
My coverage using Today’s Options began effective 2/1/2006, regular monthly premiums were deducted from my social security check each month and I assume Medicare reimbursed you for my payments. It’s my understanding that your company is paid a premium by Medicare for providing your services. If that is true, I believe it makes your business, my business. When I sense a problem, I feel I should be able contact someone in your customer service, who can give me a valid answer to resolve my question. It has been a rare occurrence for that to happen. I would think, the more costs you report to Medicare, the more you receive in reimbursement and premiums. Why should you care if something is over-billed?
Let me mention just a few of numerous examples of my concerns or questions.
1. On 8/28/2008, I phoned customer service and spoke to a woman named “Gem”, the call ended at approximately 1:54pm. I asked for and received a telephone call reference number of #[protected] from Gem. I asked why I paid had to pay two co-pays for one visit on 12/20/2006. The visit was to a clinic in Auburn Memorial Hospital and I was treated by Dr. Kooi. Dr. Kooi billed $560.00. Today’s Options paid $203.27 to Dr. Kooi and said I had to pay $6.45 as a co pay for an office visit. The $6.45 was a reduced $15.00 co-pay due to my having reached the maximum out-of pocket limit. AMH billed $533.00 and TO paid them $89.77 and said I had to pay a co-pay of $100.00. I paid both co-pays, but according to the Today’s Options booklet on page 11, in the last paragraph of the first column, it states; “Services for which no co-pay is indicated may be subject to an office visit or facility co-payment, based on where the services are received. Remember, only one co-payment will be charged for each visit to an office or facility, no matter how many services are received during the visit or the actual costs for the services received.” Clearly, Today’s Options required me to pay 2 co-pays for this visit. I also question if the $100.00 co-pay for an outpatient clinic visit is correct. I feel if a $50.00 co-pay had been shown, I would agree because the service was performed in the hospital itself. Why is it classified as a clinic though?
2. I also advised Gem about a bill from St. Joseph’s Hospital for pre-admission testing totaling $235.60 on 10-04-2006. I advised Today’s Options failed to send me an EOB and as a result I was forced to pay SJHHC $7.23 which they indicated as the balance due, knowing SJHHC would send this to collection if I didn’t pay, I paid SJJHC on 12/18/06 with check #232. I advised Gem I had previously requested copies of all missing EOB’s at least twice previously in writing to the Houston billing office, but never received a response from them. I should not have made this payment, but due to your company’s failure to provide a timely EOB, I had no choice but to pay. How do I get my money back? She promised she would call me back this afternoon, but no call was made as she promised. Oh, by the way, I still haven’t received a copy of the EOB, even though I had also requested on previous calls and in a letter to Houston dated September 15, 2007.
“St. Joseph’s HHC 10-04-2006 $235.60”
3. I have received numerous EOB’s showing $100.00 and a three for $94.83 co-pays. I have argued all of them, but only a couple have been reduced to $50.00. I believe they all are classified as outpatient surgical procedures. The reason I am normally given that the $100.00 co-pays were assessed to me was due to non-notification. I point out that it is my opinion, the only time notification is required is for a planned inpatient hospital stay. In fact, I called the person who sold me your policy, his name is Kyle Fenton and he confirmed my opinion was correct. To further support my opinion, I advise that I telephoned your customer service representative Claudia on 2/8/2006 to notify you that I was going to a podiatrist on 2/9/2006. Claudia advised that you didn’t require any notification for this, and only inpatient stays at the hospital required notification. How your representative can tell me that and then later you use non-notification as the reason troubles me deeply. I also called a representative named Mary Ward on 4/6/2006, she reiterated no notification was necessary.
Unfortunately, as I write this letter I honestly believe no one will answer me. This would be normal for this company. If I don’t get a satisfactory resolution to these problems or no one responds to this letter, I plan on notifying the Attornet General of New York, and the New York State Insurance Department, asking for their assistance.
Stephen D. Engler