ComplaintsforSpace Coast Sleep Disorders

• Initial Complaint

  01/05/2022

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  I am a commercial airline pilot. The**** (*******************************) required me to get a sleep study to keep my medical certificate. I chose Space Coast Sleep Disorders Center because they are "in-network" with my insurance company *** (*****************). Prior to the sleep study Space Coast Sleep Disorders notified me that *** was denying to cover the test. Under our Crew Assistance Program at ********* Airlines, If a test or procedure is required by the**** then *** has to cover it. In order to satisfy *** I had to obtain a letter from the****. I explained all this and provided documentation to Space Coast Sleep Disorders Center. While we we were waiting for the**** letter and final *** approval I had the test and paid out of pocket ($679.80) knowing that I would be reimbursed. *** approved the test and reimbursed me ($497.03) and explained that was their agreed upon in-network rate with Space Coast Sleep Disorders. They explained that the difference ($182.77) "plan discount" should not have been charged and should be returned to me by Space Coast Sleep Disorders Center. I provided the explanation of benefits (EOB) to Space Coast Sleep Disorder Center and requested to be reimbursed the overcharge. For several weeks they have ignored my emails and failed to return my phone calls. They finally responded by email stating they do not owe me a refund. The practice of charging a patient the difference between in-network agreed upon rates and your standard or out of network rate is called balance billing. Since I am insured by ***, and chose Space Coast Sleep Disorders Center because they accept *** and are in-network, I should not be charged (balance billed) more than the agreed upon rate.

  Business response

  03/21/2022

  Business Response /* (1000, 11, 2022/02/02) */ Contact Name and Title: Tony S******, MBA, RPSGT Contact Phone: 321-255-9901 Contact Email: ******************************** Mr. ****** originally came to Space Coast Sleep Disorders Center (*****) as a patient with ***************** (*****) and requested an in-laboratory overnight sleep study. Subsequently, ***** denied the request for an in-laboratory overnight sleep study. Despite the denial of the sleep study from *****, Mr. ****** needed the sleep study to return to work and agreed to pay the self-pay rate of $679.80. At that point, Mr. ****** was informed that he was self-pay and ***** would not bill ***** for the cost of the study. Several months later, Mr. ****** successfully billed ***** for the procedure and was directly reimbursed the *****/***** contracted rate which was $497.03. (Please keep in mind that our contrated rate varies depending on the insurance company, ***** contracted rate is $854.06.) ***** called us to inquire about overcharging Mr. ****** since he was a ***** member. ***** informed ***** that we did not and will not bill ***** for the study due to their denial for the sleep study at the date of service 09/29/2021 which resulted in Mr. ****** paying our self-pay rate of $679.80 for service. The ***** representative understood and hung up. Mr. ****** states that we balanced billed him. That consists of billing an insurance company, receiving the contracted rate and charging the patient an additional fee on top of the contracted rate. It is highly illegal and was certainly not the case in this situation. Mr. ****** was informed up front when ***** denied his sleep study that he would have to pay the self-pay rate of $679.80 and ***** would not bill ***** for the cost of the study. Mr. ****** agreed to directly bill ***** for the cost of the study. ***** did not balance bill Mr. ****** nor did we over charge him. Due to his lack of insurance coverage at the date of service, he was charged our standard self-pay rate. Please remove Mr. ******'s consumer complaint from the BBB website as his complaint is false. Consumer Response /* (3000, 13, 2022/02/13) */ (The consumer indicated he/she DID NOT accept the response from the business.) I only agreed to self pay because I was informed by Space Coast Sleep that they were appealing the original insurance denial on my behalf. I was led to believe that once approved, ***** would be making payment to Space Coast Sleep and they would be reimbursing me for the study. Furthermore, ***************** requires in-network providers to aid members by filing appeals. The agreement is not mislead or dump members and charge them a higher rate. (charging member patients the difference between normal charges and insurance agreed upon rate by definition is "balance billing"). I was not informed by Space Coast that I was no longer considered a ***** member by self paying during the appeal process. I would not have agreed to not being considered a ***** member. I was not told that I was being charged a different rate than the ***** member rate. I was not told that Space Coast was not billing ***** for the sleep study. I was told the opposite. This is a false statement. Space Coast told the ***** representative that I signed a waiver stating that I agreed to pay a different/higher rate. I have no knowledge of signing such an agreement. I have asked Space Coast Sleep for a copy of this waiver they claim I signed. They have not provided me a copy or even responded to this request. I believe they made false claim to the ***** representative. Space Coast Sleep billed ***** for CPAP equipment that was mailed to me after the sleep study. So if they claim I was no longer considered a ***** member, why did they obtain insurance approval from ***** for the equipment. Space Coast Sleep has threatened me with litigation for slander. As you are well aware that would require me to make false statements which I have not. Disagreements regarding healthcare cost by providers and customers occur every day. This intimidation tactic instead of trying to resolve this issue amicably is an unethical and unprofessional way to conduct business. The Explanation of Benefits that I attached to my BBB complaint has all the information that proves my claim. It list Space Coast as the in-network provider and me as the in-network member, end of story. Business Response /* (4000, 16, 2022/02/23) */ I have previously submitted the email to BBB from ***** to the patient stating that the patient would be self-pay and pay the standard self-pay fee ($679.80) for the overnight sleep study. The email for self-pay transpired because of the denial for coverage of the sleep study by his insurance company *****. As a consequence of the denial of service from *****, he was informed both verbally and in email that he would be self-pay going forward at the time he was scheduled for service. He was verbally informed that ***** would not have any further dealings with *****. In 17 years of business, we have never been able to overturn a denial and retro-bill ***** nor any other insurance company for a sleep study that was initially denied. Regardin our self-pay rate; it has been the same since 2005 and is the same for every person across the board. Additionally there was no self-pay waiver that ***** asked him to sign, I don't know where that came from. Furthermore, ***** did not bill ***** for his CPAP device. It was billed by Nationwide Medical based out of California. To set the matter straight, the patient should refer to his Explanation of Benefits (EOB) from *****. The EOB will give a detailed summary of the procedure codes, amounts covered by ***** and the amount he owes as well as the billing provider. In this case, Nationwide Medical will be the provider. Bottom line is this: This patient wanted a sleep study ASAP. His insurance company denied the sleep study but he still wanted to have it done ASAP for clearance to return to work. ***** was booked out several weeks but moved people around to get him in right away and rushed the results to the physician to get the prescription to get him set up on CPAP right away so that he could meet the *** requirements to return to work. In between all of this, we received numerous emails and phone calls from said patient asking for assistance with mask advice, compliance reports and getting in the sleep specialist to meet the *** requirements to return to work. Although the sleep specialist was booked out 2 months, we coordinated with his office to get him in right away so he could be cleared to return to work. We have repeatedly gone out of our way to help him get back to work but none of our efforts were ever appreciated by this man.

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