ComplaintsforOscar Health Care Plan Inc

• Initial Complaint

  07/08/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I have been taking testosterone injection for 9 years with my pcp for low testosterone that is well documented in my charts and that all my insurances companies in the past did covered the medication including Oscar health that covered testosterone injection 2 years ago. I have a meeting on Monday with my Dr because this medication is medical necessary and will cause harm to stop all the sudden. I just have surgery and it has been Almost 2 weeks since my last injection since the denied. Oscar customer service is in la ***** and unfortunately they are lost and don't understand the medication system and every time you call they either don't know or won help and will keep transferring you to different extensions. We need a supervisor in *** that can explain in detail what my doctor needs to send or call to be able to fix this issues. Please help this people are inhumane and don't care at all about my health. Fyi.. I am a registered nurse in *** and know how the system and insurances works and they are denying the claim with out a proper grounds for denial. I am trying to find a solution between Oscar and my dr other wise if this don't work I will have to get legal help. My doctor already sent paper work and on Monday we are meeting to see if we can contact oscar directly.

  Business response

  07/18/2023

  Thank you for contacting Oscar regarding the concerns expressed on behalf of our member. We have researched this case and determined the following: 
  Our member expressed dissatisfaction regarding the denial of her medication issued by Oscars Pharmacy Team. The member states that she has had difficulty obtaining her medication and is requesting the assistance of an Oscar supervisor.
  Due to the public nature of the BBB forum and the sensitive nature of this matter as it pertains to member medication and medical diagnosis the Plan cannot provide details in this response. This is not an appropriate or secure forum to discuss this issue in detail with the member. Kindly note, we are responding in good faith with the limited information we can provide on a public forum. If our member would like a more detailed response we would encourage them to contact Oscar directly for assistance so that we might provide our member with a more detailed response in a non-public forum.
  Our records show that our members provider had submitted a prior authorization request to Oscars Pharmacy Team for prescription medication. This authorization request was denied due to the lack of medical necessity. The denial indicated that our member could work with their provider to submit new documentation to support medical necessity and appeal the denial. Please note, Oscars Pharmacy Team processes all prior authorization requests based on the information submitted by the prescribing provider.
  As of the date of this correspondence, our members appeal has been received and processed by our Pharmacy Team. As such, a determination letter was issued and mailed to the members address on file. We can confirm that our member has been working closely with an Oscar supervisor in reference to their medication authorization request and has been notified of the authorization determination directly.
  
  

  Customer response

  07/18/2023

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution would be satisfactory to me.  I will wait for the business to perform this action and, if it does, will consider this complaint resolved.
  
  Regards,
  
  *************************
  
   
  

• Initial Complaint

  06/30/2021

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I have got a double claim for one procedure. It has the same date of procedure, same code, same description, but not the same amount. Also, I can't get the *** (PDF, official document) to open the claim at the Department of insurance. I can only see this claim on their website.Customer service only regrets my situation and advises ask from the hospital. Yes, I sent to Oscar an answer from the Hospital but they talk about some other code that none of us have seen, but it exists somewhere, which does not allow them to process the claim normally.Oscar, please solve the problem with my claim, provide me all official documents for open the complaint with the Department of insurance or close this doubled claim.

  Business response

  07/19/2021

  Dear Better Business Bureau,

  
  Thank you for contacting Oscar regarding complaint ID ******** related to our members
  dissatisfaction over two claims being filed for one date of service. I am writing to confirm that we
  have reviewed this case and have determined the following:

  
  The claims filed were for a single date of service, however one is for the facility and one is for the
  providers services. Respectfully, it is not a double claim as the member is asserting. Often when
  members have procedures or care at a facility they will receive two bills: one for the facility charges
  and one for the providers charges. Oscar confirms that is the case here.

  
  Upon review of the claims Oscar confirms that both were processed correctly per the members
  2021 benefits and no refund is due. The member is contractually required to meet her deductible
  for services before Oscar pays a percentage. At the time of the services the member had not met
  her deductible which is why she is responsible for the costs.

  
  The member was sent copies of the Explanation of Benefits for both claims via mail at the address
  on file. Should she wish for additional copies she can request them from member services. Oscar is
  unable to provide them through the Better Business Bureau as they contain private health
  information.

  
  Kindly note, Oscar is required to process claims as received by the provider. If the member is
  disputing the services billed for she will need to contact the provider as Oscar cannot legally change
  or alter claims.

  
  Oscar cannot address the members concern over some other code that isnt allowing the claim to
  process correctly. There is no correspondence relating to this issue and the claims are confirmed to
  have been processed correctly per her benefits.

  Respectfully, it appears that the member believes that the services conducted should fall under a
  different benefit with a different cost share. However, the Plan has confirmed that this was
  processed correctly under the members benefits. Oscar is responding to the members complaint
  that she filed directly with Oscar. This will contain detailed information that cannot be provided in
  the BBB response.

  
  For future care, in order to understand what costs may be assessed the Plan recommends the
  member contact the provider ahead of time. Once she knows what the provider plans to ****, the
  Plan can assist her in understanding how the care will be covered under her policy and what her
  costs may be.

  
  If our member has any questions about this information she can contact our Member Services
  Department at 855-OSCAR-55 or *********************************.

  
  Thank you,
  **************
  Grievance ******************************************* Corporation

  Customer response

  07/21/2021

  Hello,

  Why weren't contract prices for insurance used in this case? 

  Usually insurance clients have a discount from hospital charge.

  Thank you.

  Business response

  10/15/2021

  Dear Better Business Bureau,

  
  Thank you for contacting Oscar regarding your additional questions related to Complaint ID
  ******** pertaining to our members dissatisfaction with two claims filed for one date of
  service. We have reviewed this request for additional information, and have determined the
  following:

  
  As referenced in our prior correspondence, Oscar has confirmed that both claims which are in
  question were processed correctly per the members 2021 benefits. Additionally, should copies
  of the Explanation of Benefits (EOBs) still be needed for the members review, these can be
  requested by contacting member services. Oscar is unable to provide them directly to the ************************* as they contain private health information.

  
  Oscar acknowledges the members additional inquiry regarding the pricing for each claim. The
  member is encouraged to review her aforementioned EOBs. Again, please note that the allowed
  amount for each claim in question has been confirmed to be correct, and per the members
  policy details, she is responsible for the full allowed amount, due to her deductible, before Oscar
  pays a percentage of the cost share.

  
  As previously referenced, Oscar is required to process claims as received by the provider. If the
  member is disputing the services which were billed she will need to contact the provider to
  request any corrections, as Oscar cannot legally change or alter claims.

  
  If our member has any questions about this information she can contact our Member Services
  Department at 855-OSCAR-55 or *********************************.

  
  Thank you,
  ************
  Grievance ******************************************* Corporation

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