ComplaintsforCala Hills Endodontics, P.A.

• Initial Complaint

  04/01/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  On my Jan. 15, 2024 appt. with Cala Hills Endodontics (Lecanto, **), the receptionist initally thought I was there for a dental procedure and told me that my co-pay was $300. I showed her my written referral slip for a consultation from my dentist. She got out her calculator and started adding up what my co-pay would be, which was $86. I immediately paid the bill. After Cala Hills submitted my claim, I received a bill from them for $54. I spoke to the receptionist at **** Hills and she advised me that my insurance company (Mutual of Omaha) initally stated they cover consultations, but now they're not covering it. I called Mutual of Omaha and was told that they do not have any policies that cover consultations. After reflection, I realized that Cala Hills was not being truthful. I was standing right in front of the receptionist when she recalculated by co-pay after I gave her the written referral. She never got on the computer or called anyone. She stated my co-pay was now $86. If I would have known in the beginning that my total out-of-pocket expenses would have been $140, I would have cancelled the appointment. I believe Cala Hills violated ***************************** Representation of Fees, Section 5B.I'm seeking resolution of Cala Hills owning responsibility of misrepresenting my financial portion and writing off any remaining balance.

  Customer response

  04/01/2024

  The disputed amount is incorrect. It should be $54. The amount I paid is $86 and that is justified. They're now billing me an additional $54, which I am disputing.

  Business response

  04/17/2024

  We contacted the patients insurance company on 1-11-2024 and spoke with ******. We were told that endodontics are covered at 80% after a $50 deductible was met. We don't know exactly what a patients insurance will cover that's why we have them sign that it is just an estimate. We even wrote off an additional amount her insurance states she should have paid ******. She did pay $86.00. I sent the paper work that the patient signed so they now it is not a guarantee of benefits. Please let me know if I can be of any other assistance.

  Customer response

  04/19/2024

  I spoke with my insurance carrier on 4-19-24 and was advised that when Cala Hills talked to Amaris on 1-11-24, they requested coverage amounts for a root canal- Code 3348. I was not there for a root canal. I was there for a diagnosis. So Cala Hills mistakenly requested coverage for the wrong intended visit coverage. 

  On 1-15-24, when I told the receptionist that I was there for only a consultation/diagnosis, she did not call my insurance again to get new coverage/estimate. On Cala Hills Financial Arrangements document, it states - Insurance: This is only an estimate based upon information your insurance company provided to our office. 

  I completely understand why this statement would be in that document. They are a business and have to make a living. However, they did not contact my insurance carrier again to get another estimate after realizing I was there just for a diagnosis/consultation. As their Financial Arrangement document states, the estimate is based on information provided by my insurance company.  They did not get a proper estimate. 

  I do not think there was any malice in this situation. But I would have not gone through with the consultation if I would have known that I would be charged a total of $163.00

   

   

  Customer response

  04/19/2024

   
  Complaint: 21514932
  
  I am rejecting this response because: I spoke to my insurance carrier on 4-19-24 and was advised that when Cala Hills talked to Amaris on 1-11-24, they requested coverage amounts for a root canal - Code 3348. I was not there for a root canal. I was there for a diagnosis {code D9310), so Cala Hills mistakenly requested an estimate for the wrong visit coverage.

  On 1-15-24, when I told the receptionist that I was there for only a consultation/diagnosis, she did not call my insurance again to get a new coverage/estimate. On Cala Hills Financial Arrangements documents, it states- Insurance: This is only an estimate based upon information your insurance company provided to our office.

  I completely understand why this statement would be in that document. They are a business and have to make a living. However, they did not contact my insurance company again to get another estimate after realizing I was just there for a diagnosis/estimate. As their Financial Arrangement document states, the estimate is based on information provided by my insurance company. Cala Hills gave inaccurate information to my insurance company, therefore the estimate could not have been correct. 

  I do not think there was any malice involved in this situation, But I would have not gone through with the consultation if I would have known that I would be charged a total of $163.00
  
  Sincerely,
  
  ***************************

  Business response

  04/29/2024

  This letter is in response to a complaint filed by *************************** (referred to as "patient") of 5486 N Pecos Ter ******* Hills, FL ***** ID#:  ******** against Cala Hills Endodontics, ** (referred to as "office").  The following are responses to her concerns:  
  
  
  The patient states: "I spoke to my insurance carrier on 4-19-24 and was advised that when Cala Hills talked to Amaris on 1-11-24, they requested coverage amounts for a root canal - Code 3348. I was not there for a root canal. I was there for a diagnosis {code D9310), so Cala Hills mistakenly requested an estimate for the wrong visit coverage."
  
  
  Office response:  We contact insurance carriers as a COURTESY to our patients as well as accept payment assignment from insurance carriers as a COURTESY.  What this means is instead of the patient paying all the fees our office charges up front and having them wait for reimbursement from their insurance company the office (again as a courtesy) allow our patients to pay only the estimated charges and we then wait for payment by the insurance company.  In order to provide this COURTESY we contact the insurance company on behalf of the patient to find out an estimation of charges.  ***** times this is not accurate which is why the office always gets a reference number for the call as well as a name of the representative we spoke with.   When we verify the patients insurance benefits we submit all codes that a patient may need for that particular visit to save us time.  For example:  If a patient comes in for a consultation only we will often go ahead and ask for insurance benefits information for the associated radiographs as well as the associated codes for diagnosis of the tooth AND for root canal therapy; therefore, in the event the patient needs root canal therapy and would like to proceed we already have that information to pass on to the patient and not have to waste additional time contacting the insurance company again.  This is the reason office did not have to contact the insurance carrier a second time.  We already had the information when we called to verify benefits initially (see enclosed office insurance form).  Allow me to restate that we do this service as a courtesy to our patients and they sign an indemnity form prior to treatment that clearly states that the information we obtain from the insurance company is an ESTIMATE only as we have no control over what the information the insurance representative tells us and we can only go by what we are told. 
  
  
  
  The patient states:  "On 1-15-24, when I told the receptionist that I was there for only a consultation/diagnosis, she did not call my insurance again to get a new coverage/estimate. On Cala Hills Financial Arrangements documents, it states- Insurance: This is only an estimate based upon information your insurance company provided to our office.
  
  
  Office response:  This is correct.  ********** would not need to contact the insurance carrier again as we already had that information ahead of time.  When we verify the patients insurance benefits we submit all codes that a patient may need for that particular visit to save us time.  
  
  
  The patient states:  " completely understand why this statement would be in that document. They are a business and have to make a living. However, they did not contact my insurance company again to get another estimate after realizing I was just there for a diagnosis/estimate. As their Financial Arrangement document states, the estimate is based on information provided by my insurance company. Cala Hills gave inaccurate information to my insurance company, therefore the estimate could not have been correct."
  
  
  Office Response:  ********** would not contact the insurance carrier again as we already had the information given to us by the insurance representative (Amaris) and this was the information we used to provide an estimate for the consultation.  This was not in error on the office part.  The proper codes were given and the proper estimate (per the insurance carrier) was provided to the patient.  It is not the offices issue that the insurance did not cover what they said they would initially.  Again, this is not uncommon which is why we state up front that the estimate is only an estimate.  It is unfortunate that there is a balance remaining; however, this is a true balance that the patient owes.  
  

  Customer response

  04/30/2024

   
  Complaint: 21514932
  
  I am rejecting this response because: Cala Hills did not give me the proper insurance estimate. They only requested a quote from my insurance company for a root canal.  My insurance company has verified that Cala Hills only requested coverage for a root canal. 

  Having said this, I am willing to compromise and split the amount owed ($54) and pay $27 to close out this case. 
  
  Sincerely,
  
  ***************************

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