Tuesday, March 18, 2008

BEWARE!!!!

I have received several phone calls from LANL employees that Dr. Auge has been telling them that he is in network with United Health Care. As far as I know this is NOT true and you will be repsonsible for the service. UHC will not pay. He was terminated from UHC on Oct 29 2007

Also, if you are already in this trap, file a complaint with the Attorney Generals Office. This link will take you do the complaint form. I would also call the State Medical Board and file a complaint.

http://www.nmag.gov/office/Divisions/Inv/InvestigationComplaintForm.pdf

Here's the complaint page for the New Mexico Medical Board:
http://www.nmmb.state.nm.us/complaint.html

Friday, March 14, 2008

Los Alamos Monitor Article

Jilted claimants medical costs will be covered
By ROGER SNODGRASS, Monitor Editor
The Los Alamos National Laboratory employees who found themselves liable for medical services that they thought were covered under the laboratory health plan learned Thursday that their costs would be covered by the plan after all.
Some 35 of the claimants attended a meeting with officials of the lab’s Human Resources Division Thursday where they learned an agreement between LANL and United Health Care (UHC), the administrator of its medical plan, was “99.9 percent” done, said Rob Vitek, a spokesperson for the group.
The laboratory has acknowledged that “more than 60 employees” were facing unexpected medical bills related to problems with Physicians Medical Center of Santa Fe (PMC), which was for a period of time “out of network” for the UHC plan.
The laboratory issued a statement announcing that UHC had agreed to “retroactively treat PMC as an in-network facility.”
“This move allows all claims for services done at PMC from April 25, 2007, forward to be covered as in-network claims, paid at in-network rates with the usual deductibles and co-pays,” the laboratory said.
Claims for services provided by PMC had been rejected by UHC under terms of the medical plan. Laboratory employees who discovered there were a large number of people in the same situation began to discover they shared a common problem and organized a broad effort to have the decision reversed.
Some have said they were misled by PMC into believing that their medical services would be treated as in-network, but later began receiving bills from PMC saying they were responsible for payments of thousands to tens of thousands of dollars.
Vitek, who set up a website on behalf of the group and coordinated an intense e-mail correspondence with the others, said Thursday a planned meeting with a lawyer had now been postponed, but he said complaints had been forwarded to the New Mexico Attorney General, the state insurance board and the Public Regulation Commission.
“It is important that laboratory employees always ensure that both their physicians and the facilities in which they practice are part of the UHC medical network before services are provided,” said Lou Polito of the LANL Human Resources Division in a prepared statement.
“My lesson learned,” said Vitek, “is get everything in writing.”

ABQ Journal North Article

(Posted in ABQ Journal North March 14 2008)

Friday, March 14, 2008 LANL Insurance Provider to Cover Disputed Bills By Kiera Hay Journal Staff Writer More than 60 Los Alamos National Laboratory employees caught in a fight over medical bills incurred at a Santa Fe hospital were breathing easier Thursday after being told their medical plan provider has agreed to pay the disputed expenses. "I'm very happy with the outcome. It was the hard work of the people in the group," said Rob Vitek, a systems engineer who helped rally workers billed some $450,000 in what they considered unfair charges. "It was a grassroots effort, and it paid off," he added. The dispute began when LANL employees who received care at the recently opened Physicians Medical Center in Santa Fe were told they owed all or most of the cost of their treatment at the hospital because Physicians Medical Center was not part of the network approved by United Healthcare, the company that administers medical plans for LANL workers. Employees said it was represented to them by Physicians Medical Center that care at the hospital, located on Rodeo Park East, was covered under their plan, and they were only responsible for a nominal co-pay. Several workers said they feared that if their bills were sent to collection agencies, they could lose important security clearances. LANL said in a news release issued Thursday evening that United Healthcare, with LANL concurrence, and Physicians Medical Center have negotiated an agreement under which all care at the hospital retroactive to April 25, 2007, is considered in-network. Vitek said employees have been told to expect notification within 10 days that their bills have been paid. LANL spokesman Steve Sandoval said the lab had no comment beyond what was written in the release. "It is important that Laboratory employees always ensure that both their physicians and the facilities in which they practice are part of the United Healthcare medical network before services are provided," LANL human resource employee said Lou Polito in the statement. "Ensuring that your physician or facility is in the UHC network is important because physicians and facilities are constantly entering and leaving the UHC network," he said. Vitek said the good news he and others received Thursday was tempered upon learning that another group of LANL employees was told that care provided after Oct. 29, 2007, by Dr. W. Auge— a doctor who is part owner of Physicians Medical Center and who initially referred Vitek and others to the hospital— would not be covered by United Healthcare. Vitek said Auge falsely represented to clients that he was still part of the United Healthcare network. Auge could not be reached Thursday. "I think Physicians Medical Center got off the hook. I think they represented themselves as being carriers, and they weren't," Vitek said. A message left for Jeanne Scheide, vice president of operations for National Surgical Hospitals, part owner of Physicians Medical Center, was not returned late Thursday. "I think it (the resolution) was the goodwill of LANL and LANL pushing United Healthcare to get this resolved," Vitek said.

Santa Fe New Mexican Article

(This is from the New paper March 14 2008)
Insurance firm to pay disputed hospital claims

Anne Constable The New Mexican

3/13/2008 - 3/14/08
Los Alamos National Laboratory employees learned Thursday that United Healthcare will pay for services at Physicians Medical Center in Santa Fe after all. The insurance company had declined claims filed last year on the grounds that the hospital, located on Rodeo Park Drive East, was not in its network. Employees and some retirees who are insured through United Healthcare appealed, saying that they received written statements from PMC saying it would honor their in-network benefits. Later the hospital told them they were financially responsible for the bills. The total claims are estimated at $450,000. Rob Vitek, a systems engineer at the lab, said Thursday, "This is good news for LANL employees." For Steve Rivera, another lab employee, news of the settlement "was a relief for me, my family, for everyone." Rivera, who had knee surgery at PMC, said he was happy that "the lab stood up for us." Cheryl Randolph, a spokeswoman for United Healthcare, confirmed that the insurance company had reached an agreement with Physicians Medical Center. All claims going back to April 25, 2007, will be reprocessed as if the hospital was in the company's network. "We certainly apologize for any confusion. We're glad we were able to work out an agreement," she said. According to Randolph, the hospital should not have told patients that their insurance would be accepted. Although United Healthcare was negotiating with the hospital, "somebody may have jumped the gun," she said. PMC officially became an in-network facility under the lab's insurance plan on Feb. 11. More than 30 people attended Thursday's meeting in Los Alamos convened by the lab's human resources director, Ben Glover. Vitek said a number of retirees, who are insured by United Healthcare, were present. Lloyd Scarrow stepped down as head of the hospital late last week. A spokeswoman from National Surgical Hospitals, a Chicago chain that is part owner of PMC, declined to give a reason. Many of the 2007 claims involved procedures by orthopedist Dr. Wayne Auge, a part-owner of the hospital. At the time, he was a member of United Healthcare's network and the insurance company paid his fees. But Randolph said that Auge violated his contract by operating on patients at PMC when it was not in the network. He was suspended from the network as of Oct. 29. Contact Anne Constable at 986-3022 or aconstable@sfnewmexican.com.

Thursday, March 13, 2008

A New Battle Facing a Different Group.

( As a stated in my blog under 99.9 % below -IN RED) Well its happened and here is an example.There seems to be a pattern and the same name appears. Im sure it will not effect as many people but it hurts to see anyone having to go through a mess like we just went through. Can LANL HR post a message on the LANL Web site that Dr Auge is not a UHC provider?

I'm one of the people who is going to be hit by the next phase of this mess. My wife was injured skiing on Feb. 2nd and we went to Auge shortly after that. My wife contacted Dr. Auge's office and believed, from their responses, that he was in-network. The staff at Dr. Auge's office made a photocopy of my insurance card, could see that we were not covered, but made no effort to inform us of that fact. My wife had surgery on Feb 20th at PMC and the PMC charges are going to be covered (I believe), but Dr. Auge was the surgeon, and his bill of about $5300 is not covered (according to UHC). HR told me that it will be difficult to get UHC to cover the expenses since Dr. Auge was dropped from the network, unlike PMC which had not yet been added to the network.

We were not patients of Dr. Auge's at the time when he was dropped from the network, so we didn't get any message warning us of the fact. LANL HR told me that UHC sent Dr. Auge certified mail telling him that he was no longer in-network, and that he shouldn't pass himself off as such, back in October.

LANL HR told me that I was the first case of this kind that she had heard of (where PMC is covered but Auge not), but that more people are is the same boat.

I called his office today. I told them that I understood that they weren't in-network service providers for UHC and the woman who answered the phone (Ruth) said "We are, but Dr. Auge isn't". When asked if it was their policy to inform people that they aren't in-network, they ignored the question and asked about my wife. They told me that she would be covered under her "global period" -- her 90 day period after surgery. When I pointed out that Dr. Auge wasn't covered during the surgery, she said that she would have Sarah get back to me. From what Ruth said, I guess it is Sarah's job to deal with these problems.

I expect I will have to do something akin to what all of you have already done, but I doubt that the same solution can be applied.

I sure didn't need this.

99.9% Chance UHC Will Pay

This morning LANL HR held a meeting with the employee’s effected by this insurance fiasco. I would like to say the news is very good and there is a 99.9% chance all of us Lanl and Non-Lanl employee’s who were insured by UHC and had a procedure done at PMC will have their claims paid. I have received word the agreement was signed by Lanl and since its UHC's agreement I can say with a fair amount certainity the problem for us 70-76 employee's is now behind us. This would include those no-LANL employee's as well, I personally asked if non-lanl would be included at the meeting. We should all be getting a letter from UHC within 10 days. Also, be sure to check your EOB's.
I want to thank LANL HR for stepping up to the plate and for helping to get this done, its a huge relief.

Now then and this is very important... There may be people who have seen Dr. Auge after Oct 29th, 2007. You should know that as of that date, Dr. Auge was terminated as a UHC carrier. You may have been lead to beleive he is still in network with UHC but UHC will not pay on this claim because he is not. Your recource is to write to the New Mexcio Medical Board or call them at 1-800-945-5845 or locally at 476-7220 and file a complaint. I'm not preavy to the amount of those effected by this and I sure hope the amount is minimal. Ouch! Maybe another mess.

LANL HR said It was our grass roots effort that made this materialize. The Newspapers (LA Monitor and Santa Fe New Mexican), this blog and contacting State Agencies put this issue in the open. We should all be proud for the hard work we did.

On another note: personally I think PMC and the doctor (Dr, Auge) got left off the hook. I would expect, but I do not know with certainty, that this issue is not over for these parties, I hope not because it has smelled very fishy to me from the start. I would guess the Attorney General’s office and the Public Regulatory Commission may still continue their investigation into this matter. I feel UHC can do a better job in communicating to LANL employee's and LANL retirees. LANL retiree's are really out on their own and there needs to be a way of getting insurance information out to these people. LANL also needs to make sure UHC is doing it's job and providing outstanding service to the employee's. UHC has issues like any other insurance carrier. You need to get the issues into the open and get them fixed. PMC ...I will stick to my guns and say they were ultimately the blame for this mess.

My lesson in all this: Get everything in writing, verbal agreements don’t mean anything these days. If you call to find out if your insurance carrier will cover you for a procedure at least get a case number and make sure the conversation is recorded or please save a huge hassel and get it in writing.

Tuesday, March 11, 2008

Lyodd Scarrow Forced to Resign From PMC

Our group has learned Mr. Scarrow was forced to resign his CEO Position with Physicans Medical Center (PMC) . How this came about is un-clear but one could only guess. People are being hurt by this mess and beleive me it is NOT the fault of the good LANL Employees. We are only fighting for what is right and doing it the way we seem fit. We were told point blank it was up to us to handle this matter in what ever way we deemed. LANL employees are NOT stupid people and when you open up a bee hive you can expect to get stung.

LANL Employees At A Crossroads

LANL has called a meeting for 8am Thursday March 13, 2008 at the Physics Auditorium. A clearance (L or Q) is not required to access the Physics Auditorium.

We are all anxious to hear what will be conveyed to all 70 LANL employees. I have sent a note to LANL HR asking for a update since we are scheduled to meet with an attorney Wednesday March 12th to discuss a path forward. I would think some sort of decsion has been made regarding this matter at this time.



Stay Tune

Monday, March 10, 2008

More Lies

How I came to be in this situation is similar to all the others. My doctor told me that they received approval from UHC to have the surgery done at PMC. When I went to PMC I was given the paperwork that everyone has apparently gotten stating that PMC, knowing that they were out of network would take me in as an in network patient. Does this sound familiar? When I first became aware that UHC refused my claim I immediately contacted Dr. Weiner's office. His assistant told me that they had received approval and they referred me to Lloyd Scarrow at PMC. If someone can't take the word of the person who is going to put you under and perform surgery on you, whom can you trust? I also called Lisa Castellaw at PMC and she assured me that I was only going to be responsible for 10% as indicated and that a contract had been signed with UHC. Days later I received a bill from PMC for the entire amount. I spoke with Lloyd Scarrow on the phone and in person several times. He told me many things that I believe to be untruthful and unscrupulous (I will elaborate further another time if need be). These unfortunate cases of misinformation or lack or communication or whatever you want to call it are probably causing lots of people undue stress. Hopefully an agreement can be worked out soon with all involved. Stay tuned.

Thursday, March 06, 2008

Rumors are Flying

As of today some of us were made aware that UHC was going to pay PMC on these 70 LANL employee's claims which totals about $450,000. About 3 hours after hearing what we thought was great news we have been told it's not true. I have also learned that something may be in the works to get this settled once and for all.

I can assure you we will not let down on this. 70 LANL employees did not make a mistake. Think about it! We are not stupid people! Where is the common sence in all of this. Do you really think 70 people went out of their way to use a NON UHC provider so we could pay for our surgeries out of our own pockets, Dah! Thats sure make sence. Do you think we all have thousands of dollars just lying around to pay for bills in which we pay insurance companies to protect us from. Someone mis-lead us into beleiving we were getting something (which we pay for anyway) and then ripped the carpet from under our feet.

Rob

Another Sad Story

(Another Decieved Person writes)

Rob:
We are one of the families who have been "stiffed" by Dr. Auge and PMC, UHC. Our son had knee surgery in July 07. Recently, we received a bill for over $4900 saying UHC had denied our claim. In addition, we were called by the anesthesia company and informed we owed $720 for just the anesthesia. They were working on a claim to get the anesthesia covered and yesterday I received a bill from them for $72, so they must have been able to get it covered. However, I received the same letter that many others did that the hospital bill would not be covered! I called UHC and was told by the claim representative that "You never trust a doctor, it is your responsibility as the insured to make sure the facilty is covered." I asked to speak to someone higher up and she said that no one else would be able to help me. She suggested the same failed appeal that others have conducted. Yesterday I paid PMC almost $1000 as I did not want a ding on my credit. What if anything can be done about this blatant misrepresentation by Dr. Auge and "his" hospital? Thanks for your help.

Wednesday, March 05, 2008

Doctor Closes Office in Los Alamos

Word has just been received that one of the doctors involved in this mess, Dr. Auge, has closed his pratice in Los Alamos. Dr. Auge is part owner of PMC and it really makes me wonder why he would refer us to PMC to have our procedure done if he knew we wouldnt be covered. I still think PMC decieved us LANL employee's into thinking we had coverage for our medical procedures. I still think PMC is ultimately responsible in correcting this issue. However I do feel UHC and the Lab should help its people understand what's occuring instead of not getting involved or helping.

My guess: LANL legal has told LANL mangement to not get involved. Why?
Why would UHC recently sign a contract with PMC knowing this has occured?

Monday, March 03, 2008

Week Summary

A few people had a meeting with LANL HR benefits office as well as with the directors staff. Information is provided in the blog as to some of the meetings contents. Its all still very much a mess and pain staking to say the least. PMC wants it's $450,000 from LANL employee's.
My group email list is now at 25 people. I would like to see all 70 who are feeling the effects of this mess be informed.
  1. Many people have written several letters to different agency's in New Mexico. The agencies include the Attorney Generals Office, The New Mexico Insurance Commision, The Govorners office, US Deptartment of Labor, etc. We are still waiting for official replies.
  2. LANL HR has told us they will try to hold a meeting with us within the next two weeks to inform us of their take and what they can and cannot do to help. It seems at this time HR hands are being tied by LANL legal, why is uncertain.
  3. UHC still has denied all of our claims and expects us to fork the money over to PMC for our procedures. Another words, our insurance failed us.
  4. PMC has written each of us letter expalining why they have to bill us stating ," UHC and LANL are the cause of this mess." This letter is located in the blog. Seems PMC was paid by UHC before by LANL patients using PMC but us 70 employees have been left in the dirt.
  5. Get this, PMC now has a bonified contract with UHC.
  6. I have left my perspctive in the blog as to why this occured and I will stand by it until proven other wise.
  7. Dr Auge's office keeps telling people to appeal to UHC. We have all done this and have been denied. No statement has been recieved from Dr Auge's office regarding this issue.
  8. It has been agreed that the blog will continue to be open for all to read. We would like others at LANL to be informed of this mess to that maybe we can save them from this hassle for anything they have done.

Sunday, March 02, 2008

Employee Perspective After Meeting With LANL HR

(Employee's perspective after meeting with LANL HR)

1-March-2008
Here is a short summary of a few things I've learned recently that I thought others might be interested in.1) I met with Ben Glover (HR division leader), Lou Polito (HR Benefits group leader), and Maria Russell (HR Benefits Design and Administration group) on Wednesday Feb. 27. This meeting was informative and reassuring. It is very clear to me that HR is "paying attention" to this issue and takes ownership of our healthcare insurance benefits and policies. They are not just "passing me off to UHC" or letting me fend for myself. I learned a bit more about the dispute itself, and I gained an appreciation of the legal constraints HR must operate within. I believe that HR may be our most significant ally, but we need to be patient. HR *cannot communicate* about some things with us; we need to accept that. HR will organize a meeting with all those involved with this dispute, perhaps in two weeks.2) Ben Glover assured me that at this time there is no reason to worry that this billing dispute will have an adverse affect on our clearances. That is also true for those of us in HRP. And we do not need to take any proactive step to inform anyone in the security division.3) It is important that we exercise all of our ERISA rights and exhaust all possible avenues before we try to go to court. And this is true not just for claims against UHC: it is true for claims against PMC (that surprised me). So, what are our ERISA rights? I'm learning about this, but the first and most obvious is that we have the right to receive the reason for denial of a claim "in writing and in a manner you can understand." I have already received a letter in response to my appeal to UHC, but this letter was ambiguous and I did *not* understand it. So I have taken my appeal to "the second level" and asked for a clearer explanation. Going to this second level in the appeal process is important if you are trying to exercise ALL of your ERISA rights.

Saturday, March 01, 2008

Once Again, Another Story, On and On they continue!

( Any person can see the same pattern has occured. This same pattern happens to 70 LANL Employees. Why didnt UHC or LANL notify the employee's via the LANL internal Communications of this PMC situation? LANL has a UHC representative on-site, there's no excuse. This could of easily saved many people from this mess)

Hi Rob,
Thanks, on sending all the previous emails and providing the link for the blog. There is a lot of good information being shared with everyone. My husband had surgery on June 6th, 2007, at Phycians Medical Center in Santa Fe, at the time also we were under the impression that United Health Care would cover the cost of his surgery $5,020.00. We received a billing statement from PMC in mid January 2008, I then called and wanted to speak with some one about the bill, I was given the name of Lisa (sorry don't have her last name) I've left my name and phone number so that she could return my call, she never returned my calls. The last week got a letter form PMS stating at UHC wasn't covering the cost. I then called Dr. Auge office in Espanola, and spoke with Janet and gave me the name of Lloyd Scarrow once again left my name and phone number for him to call me back, haven't receive a call back. What I would like to see out of this that UHC would make every effort in helping all of us with some payment of our medial bills from PMC in Santa Fe, and I'm concerned with my Q clearance held here at Los Alamos National Laboratory, with the outstanding costs not being paid by our insurance with UHC.