ComplaintsforSalameh Plastic Surgery

• Initial Complaint

  07/17/2023

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  "BBB does accept complaints such as billing disputes or customer service issues." I have a health condition, bilateral lower extremity lipedema. The treatment for this is ******** *********** surgery to remove inflamed tissue to reduce pain and swelling. I was pre-approved for coverage for this surgery by TriCare/Humana Military. We paid the provider, ******* ******* Surgery, $9,900.00 out of pocket to secure a scheduled surgery appointment. The surgery was on August 30, 2022. The insurer has repeatedly denied claims filed by me (the beneficiary) because they say the provider was in network on 8/30/22 and is therefore obligated to submit the claim on my behalf. The provider has stated repeatedly and adamantly over many months that were not in network and will not submit the claim. The insurer has a contract showing that in fact the provider WAS in network on 8/30/22, and thus the provider has been untruthful in their communications with me, and has not fulfilled their contractual obligation to submit the claim on my behalf.. The insurer called the provider to indicate that they had such a contract, and subsequently mailed a copy of the contract to the provider. Hence the provider has in hand proof that they were in network on 8/30/22. The beneficiary has made repeated calls to the provider and received absolutely no response. What we seek: At a minimum, the provider should submit the claim to Humana Military within 10 business days, and refund our out-of-pocket $9,900.00 immediately. Ideally we would like an additional sum to cover the interest on our out-of-pocket $9,900.00 over the interim period, which is now 11 months. Ideally I would like an apology for being lied to many times over that 11 months.

  Business response

  08/18/2023

  I am writing on behalf of my client, Salameh Plastic Surgery to address the complaint filed by ****** ******* within the 7-day response time.  Currently, Salameh Plastic Surgery is working with *** ******* and her insurance in order to provide her with all available compensation from her insurance. Generally, my client doesn't bill insurance for these procedures.  In doing so on this patient, there was a mix-up that my client is attempting to resolve.   
  
  
  Cole, Loney PLLC
  
  **** ** ******
  
  
  

  Customer response

  08/21/2023

  
  Complaint: ********

  I thank the BBB for their help. 
  
  I am rejecting this response because:

  After the insurer sent the provider proof that the provider WAS in the network on the date of my surgery and therefore contractually OBLIGATED to submit the claim on my behalf, the provider's office told me when I called them in July that they would submit the claim. Per the insurer, they have not done so and what's more, the provider told the insurer that they WOULD NOT submit the claim. 

  Following lack of action and refusal to abide by contractual obligations by the provider, the insurer (Humana Military) has referred this issue to the Defense Health Agency's Program Integrity Office on 8/15/23.

  I suggest that the attorney should

  (1) Obtain from the provider the copy of the contract that specifies their contractual obligation to submit the claim as long as they were in network with the insurer, which they were on 08/30/22 (date of my surgery).

  (2) Unless the attorney has documentation to prove that the provider was NOT in the network at that time, the contract holds, and the attorney should advise the provider to submit the claim. 

  (3) If the attorney can prove that the provider withdrew from the network sufficiently in advance of 8/30/22, this proof should be provided ASAP to the insurer, who would then be able to pay the claim that I submitted. 

  
  Sincerely,
  
  ****** *******

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩