ComplaintsforAmanda Thomas, LLC

• Initial Complaint

  07/01/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I went to Amanda Thomas LLC in February 2024 to purchase a cranial prosthesis (wig). I have ********************************* and Amanda Thomas LLC is an in-network provider for this insurance. I was informed that my wig would cost $1,618 and that insurance would only cover $375 of that amount. I was informed that I needed to sign a waiver of responsibility, stating that I would pay any remaining balance if my item was not deemed medically necessary. I signed this waiver, as I was told that I was required to, in order to obtain the wig I had chosen. I paid $1,243 out of pocket (with my HSA card) and $375 was billed to my insurance. Amanda Thomas submitted a claim to BCBS for only $375, instead of the full amount of $1,618.00. My HSA company fought my payment, as they did not have sufficient proof of the expense. I have been in contact with Amanda Thomas and BCBS in attempts to resolve this issue. I asked that Amanda Thomas LLC re-submit the claim for the correct amount of $1,618, which they did. I asked that BCBS amend the Explanation of Benefits (EOB) with the new claim amount, which they did. On the amended EOB, I noticed that BCBS had a discount of $1,243 taken off the balance, with the final bill to me being only $375. I asked BCBS about this $1,243 discount, and they explained that Amanda Thomas is an in-network provider, which means they are to provide any medically necessary product/wig at the contracted rate of $375; it is illegal ("Balance Billing") to bill the patient for the remaining balance that is not covered by insurance. I confirmed with BCBS that the waiver I signed would have applied only if my wig was not deemed medically necessary. However, it was deemed medically necessary, approved by insurance and the insurance company paid their contracted, in-network rate. Amanda Thomas attempts to hide this illegal Balance Billing practice by calling it an upgrade charge.

  Customer response

  07/10/2024

  We just received the attached letter from our FSA company (Voya) stating that the charge for $1,243 at Amanda Thomas is "ineligible" for payment, and they are demanding we repay them this money. I had appealed this decision 3 times previously before receiving this notice.  **** has determined that it is an ineligible purchase because **************** EOB states that the balance after insurance payment ($1243) is not to be paid by the consumer, as Amanda Thomas is an in network provider. 

  Initially, I was not seeking reimbursement for this purchase, but instead just review of potentially incorrect/illegal billing practices. Given this new information, I am now requesting reimbursement for the $1243, so that I can pay it to Voya, as requested in this letter. 

  Business response

  07/25/2024

  We are contracted with ***************** Blue Shield of NH.  They set the amounts for what is considered medically necessary.  For a Wig/Hair Prosthesis, NH Anthem BCBS has deemed that $375.00 is what the covered benefit is regardless of what patient plan states is covered.  We are very transparent about this coverage and offer other products that are under the $375.00.  When a patient chooses a product that is above this allowable, they sign an upgrade waiver acknowledging the out of pocket cost to the patient.

  
  When ******** made her purchase, she was aware of the cost to her, signed the waiver and paid the balance with her FSA card. The original claim was submitted for $375.00.  We were paid $185.23 and $189.77 was applied to her deductible, which ******** paid on 4/19/2024.

  
  On May 22, ******** called stating that her FSA was giving her a difficult time regarding the amount she paid and ask if we would resubmit the claim for the full amount, which we did. See attached claim information.

  
  We have not had any other communication with ******** and was unaware of any other problems until on 7/16/2024, when we were contacted by Anthem BCBS, claiming a grievance had been filed for fraudulent billing.  After providing all requested information, we received a letter stating the matter has been closed and grievance does not support a quality of service or administrative issue.  See attached notice from BCBS.

  
  ******** never requested a refund from Amanda Thomas, LLC and no monies are due to her.  She fully understood our policies, the process and her financial commitment.
  We have been in business for 20 years and have a reputable reputation with the medical community and public. We have strict policies in place to be transparent with the patient. 

  
  

  Customer response

  08/09/2024

  I have been away and was not able to respond to this before the 10-day period of time ended.  It is work noting that it took Amanda Thomas 36 days to respond to my initial complaint; I am frustrated that I was only given 10 days to respond before this complaint was closed. I do not agree with the outcome.
  
  As stated in their response, Amanda Thomas is contracted as an In-Network Provider with ***************** and Blue Shield of NH. Since they are an In-Network Provider,they are required to accept the negotiated rate or allowed amount as full payment, and they are not (legally) supposed to bill patients for any remaining balance.  If Amanda Thomas was an Out of Network Provider, they are allowed to bill consumers for any amount. 
  
  The **************** website further explains these restrictions (below), in accordance with the No Surprises Act of 2022:
  
  In-network providers do not balance bill
  If you are seeing an in-network provider, you will not be billed for amounts above the negotiated rate that the provider and insurance plan have agreed to (sometimes called the allowed amount).  By law, insurance companies operating in ************* must prohibit provider balance billing in their network participation contract with health care providers.   
  
  Out-of-network providers do not have a payment agreement with your insurance company, meaning they can bill you for any amount.  If you receive care from an out-of-network hospital, there is virtually no limit on what you may be liable to pay.
  
  As a result of this, when Anthem received the adjusted claim for the full $1,618.00 in May 2024, ****** stated that they would pay $375.00 and that I did not owe the remaining balance of $1,243.00.  The amended *** states 066: You dont pay the your discount amount ($1,243.00).  This is the benefit to using doctors/facilities in one of our plans.  ******** contacted Anthem BCBS and Amanda Thomas, LLC about this; Amanda Thomas, LLC stated that ******** signed a waiver agreeing to pay this upgrade cost for a wig above of the amount reimbursed by insurance.  Anthem representative stated that ******** should not have been required to sign a waiver for these additional charges, as Amanda Thomas is an In-Network Provider; Anthem stated that since I signed the waiver, there is nothing they can do.  However, they stated that Amanda Thomas billing for the remaining balance is an illegal practice called balance billing and if I encountered this situation in the future and was being required by Amanda Thomas (or another In-Network Provider) to sign a waiver in order to receive a product, to not sign, but to contact Anthem and they would speak with their compliance team.   
  
  Furthermore, ****,the *** provider, has requested that I repay the $1,243.00, as they cannot find sufficient proof that this was a valid purchase.  They found the handwritten Amanda Thomas receipt to be insufficient; when I reached out to Amanda Thomas in May about this, an Amanda Thomas employee stated that a code was left off of the receipt.  They also cannot find sufficient proof,because the *** from Anthem directly states that I should not be required to pay this amount. 
  
  Until now, I have not requested a refund from Amanda Thomas, because the *** funds were used to pay for the remaining $1,243.00 balance. However, if the *** company (****) refuses to pay this balance, because it is not a balance I should have been legally required to pay, and Voya requests that I repay them the $1,243.00, I will be seeking a refund from Amanda Thomas.  I have appealed the Voya decision with all the supporting documents that I have and am awaiting a response.
  
  I appreciate that Amanda Thomas has been in business for 20 years; however, I request that they revisit the No Surprises Act that was passed 2 years ago, as I do not believe their transparent practices are in compliance with this law.  When I was required to sign the waiver to obtain the product I chose, I was not informed that Amanda Thomas would only bill $375 to my insurance company, effectively hiding the full cost from the insurance company.  I was not informed that I would have to request that the full balance be billed to the insurance company.  I was not informed that the insurance company would state that I was not legally required to pay the remaining balance.  I was not informed that I was not legally required to sign the waiver in order to obtain the product I chose.
  
  I believe Amanda Thomas should be an Out of Network Provider if they wish to continue the practice of requiring consumers to sign waivers to cover the remaining balance not covered by insurance.  The current practice, for patients covered by an insurance listing Amanda Thomas as an In Network Provider is masking the illegal Balance Billing Practice as an upgrade charge.  

  Business response

  08/29/2024

  In network Anthem BCBS coverage policy for wigs/hair prostheses changed 1/1/2011.  Prior to this date, wig coverage was based on the patients plan. After this date, NH Anthem set the rate of what they felt was medically necessary, then $350, today $375. 
  
  Early 2011, I had many discussions with ********* C. *****, Provider Network Manager, Enterprise Ancillary Provider Contracting, ***************** and Blue Shield, he said there was nothing they could do about the coverage set for the wigs/hair prosthesis. We decided to stay in network for the ladies who had breast surgery and lymphedema so they could still have coverage for breast prostheses, mastectomy bras and compression sleeves and gloves.
  
  Unfortunately,the coverage for high end hair prosthesis became an issue very quickly.  I asked *********, How do I handle the patients who want a more luxury/expensive product? I cant offer them everything at $350, I will be out of business as that benefit doesnt even cover my cost.
  
  On May 18, 2011, ********* sent me an email with the waiver document.  Attached is the waiver form.  This would be utilized when members want a deluxe item that is above and beyond your standard product offerings.
  
  This waiver document makes it very clear to the Patient what the costs will be and by signing, they acknowledge and agree. The patient initials each line item and is clear:

  * I have been shown products within the covered allowed amount of my insurance plan.

  * I have chosen Deluxe items that is an UPGRADE above my covered benefit and may not be deemed medically necessary.

  * The amount I am paying today is considered a product UPGRADE and does NOT include an co-pays, co-insurance and/or deductibles I may have within my plan.

  *  If any of the products I received today are not covered under my plan, I understand I am responsible for the full cost of the product.

  The signature line states:  I understand and accept responsibility for any financial portion of these product(s) that are not cover by my insurance plan.  Therefore,The Surprise Billing Act was not violated, as the patient was informed in advance of the cost and agreed at the time of purchase.  We do our best to be very clear so there are NO Surprises!  We have a large inventory of products that fall within the allowable rate.  See attached photos.
  
  As far as the invoice, the **** Code was left off the original invoice. Attached is an updated invoice to be used for the *** provider.  I have also mailed ******** a copy of the invoice and included the waiver and prescription, in case the *** needs this as well.  
  
  

  We strive for 100% patient satisfaction, and it should be noted that we colored her unit two times, cut and style at no additional cost.  The approximate value of this service is $300.

  This insurance coverage for wigs/hair prosthesis with Anthem BCBS is very frustrating for the patient and the provider.  We do our best to have open communication with the patients who are already going through a difficult time.   

  Customer response

  09/05/2024

   
  Complaint: 21883583
  

  I received the updated invoice and have forwarded it to the ***************** handling my appeal for HSA denial.  Thank you.  

  I appreciate the information you provided about your waiver.  I think it important to note that the conversation that resulted in the waiver occurred in 2011.  Since that time, multiple additional laws have been passed including:
  

  -NH Prohibition of Balance Billing (RSA 420-J: 8-e and RSA 329:31-b) effective 7/1/2018

  -Federal No Surprises Act of 1/1/2022

  -NH No Surprises Act (SB173) of 7/3/2024

  I am hearing the same thing from both Anthem and the *********** - Providers that are in-network (as Amanda Thomas, LLC is with Anthem) have agreed to accept the insurance payment as payment in full (less any applicable copays, deductible, or coinsurance), and are not allowed to balance bill the patient. I think it is advised to revisit the waiver policy/process in 2024 to ensure that it remains a legally viable option, given the new laws and regulations.  

  Regarding the $300 coloring fee that was 'waived' - the wig did not arrive in the color that I chose with the Amanda Thomas, LLC stylist (understandably with human hair there is some variation).  It was a different color than my hair.  When I was educated on my options, I was told Amanda Thomas, LLC could try and dye the piece to match my hair.  I asked up front if there would be any cost for this.  I was informed that no, there would be no cost (not that there was a cost that was being waived), as it was included with purchase of the wig.  
  

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

  Business response

  09/13/2024

  Yes, we are aware of the new laws, but have not violated any of them.

  
  1) NH Prohibition of Balance Billing (RSA 420-J: 8-e and RSA 329:31-b) effective 7/1/2018

  
  If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan's in-network cost-sharing amount (such as copayments, coinsurance and deductibles). You cannot be balance billed for these emergency services.

  
  The services received were not an emergency medical condition.

  
  2) Federal No Surprises Act of 1/1/2022

  
  The No Surprises ********* is a federal law that went into effect on January 1,2022, to protect patients from unexpected medical bills. The *** applies to most types of health insurance and protects patients from:  Surprise billing: Unexpected out-of-network bills for emergency room visits, air ambulance services, and non-emergency care related to an in-network hospital visit.

  
  The services received were not for an emergency visit, air ambulance or an in-network hospital visit.

  
  3) NH No Surprises Act (SB173) of 7/3/2024

  
  *******, ** (July 10, 2024)  The ********************************** (****) is pleased to announce the passage and signing into law of SB173, a pivotal piece of legislation aimed at protecting consumers from unexpected medical bills.

  
  This was not an unexpected medical expense.  Appropriate documents were signed at the time of purchase acknowledging the product received was above what the insurance coverage allowed and .  See previous documents submitted.

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