Complaint Review: Dr. Jeff W.Cook M.D. Owner Of Franklin Orthopediacs And Sports Medicine

Ok Dr. Cook, rebuttal this!!

This letter comes directly from BCBS legal!! Read carefully below. You STILL have not addressed your obligations that you failed to do. Don't you feel that you had an obligation to file? by your contract with BCBS?


BlueCross BlueShield of Tennessee
801 Pine Street Chattanooga, TN 37402
www.bcbst.com
February 12, 2007
Mr. William T. Coward 7145 Bahne Road Fairview, TN 37062
RE: Paulette Ake-Coward
10 No.: STU412882694-00 STU901627032 Provider: Jeff W. Cook, M.D.
Franklin Orthopaedics & Sports
Dear Mr. Coward:
This is in response to your inquiry of January 24,2007, regarding claims for services rendered by Dr. Jeff W. Cook of Franklin Orthopaedics & Sports Medicine, for the period of June 20,2003, total charges $7,126.00.
The contract under which Ms. Paulette Coward was covered, State of Tennessee Employee's Group Program, is a self-funded group and BlueCross BlueShield of Tennessee (BCBST) administers the coverage. Ms. Coward's family coverage under this group was effective as of April 1 , 2003 and was terminated on November 30, 2004. The coverage was reinstated for the period of August 1, 2005 through August 31, 2005.
Thank you for providing me with a copy of the billing statement (dated February 14, 2005) for services rendered by Dr. Cook at Franklin Orhopaedics & Sports Medicine, for the period of June 20,2003 through September 15,2003, total charges $7,126.00. Please note, this Billing Statement indicates that numerous claims were filed for the services rendered by Or. Cook, of Franklin Orthopaedics & Sports Medicine, with CNA Insurance, which appears to have been the Insurance Company that represents the Waffle House for the injuries Ms. Coward received from a fall in March 2003. However, this Billing Statement does not indicate that any payments were received from CNA Insurance for the above referenced services rendered. Further, please note that the Billing Statement does not indicate that Or. Cook billed BlueCross BlueShield of Tennessee for these services.
You also forwarded to me a copy of a letter dated August 16, 2004 from Ms. Kathy F., Billing Manager of Franklin Orthopaedics and Sports Medicine, (copy is enclosed for your review) which requested help from Ms. Coward in resolving the outstanding balance on her account. She further advised that Mr. Morris Ricketts, at CNA Insurance Company, had advised her that it could take two to three years to settle the case. She also advised that CNA Insurance had paid the maximum benefits available for services
BlueCross BlueShield ofTennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association

rendered for the period of March 7, 2003 through June 16, 2003. However, there was an outstanding balance for the period of June 20, 2003 through September 15, 2003, totaling $7,126.00 that had not been paid. Ms. Kathy F. ask if Ms. Coward had a health insurance policy under which they could submit the balance of the claims in order for the claims to be paid. She advised that she was aware that most insurance companies have a Timely Filing Limit, but they could show that the maximum amount of the claims had been paid. She further advised that the health insurance would require that the money be reimbursed at the time the settlement was reached. Based on the copy of the letter you forwarded to me, Ms. Coward advised that they already had the BCBST -State of Tennessee Insurance Card on file and they had been directed to file the charges on that coverage. Ms. Coward asked her "what is the problem". Ms. Coward again gave her the State of Tennessee Coverage Identification Number of STU412882694-00.
Upon receipt of your telephone inquiry and the available information that you provided for my review, I conducted a complete review of the claims records of BlueCross BlueShield of Tennessee. To date I have been unable to locate any claims submitted for the services rendered for the treatment received by Ms. Coward that was provided by Dr. Cook. There were related claims received for services rendered by other providers that were paid by BCBST.
Dr. Jeff W. Cook is a Participating Provider in the BCBST Provider Network. The 6.8 section of his Physician Agreement addresses the Submission of Charges. The Physician warrants that all legitimate charges for all BCBST Members will be submitted to BCBST for payment. The Physician shall bill BCBST on forms and in a manner acceptable to BCBST and shall submit such complete claims within one hundred and eighty days (180) from the date services have been rendered. Failure to submit such claims within such period will result in denial of claims. (The claims will be denied as Timely Filing Limit.) If the claims are denied for timely filing the physician cannot bill the patient for the charges. Sometimes providers will delay submitting claims that are related to accidents when a third party payee is involved because they will only be paid the discounted amount of the charges as agreed to under the provider network agreement. However, most providers do submit the claims in order to receive payment for their services.
Because BCBST did not receive the referenced claims in a timely manner we can no longer make payment on the claims. Because the State of Tennessee Employee's Group Contract contains a Member Grievance Process, if the claims had been received and denied under the Timely Filing Limit you would have been offered the opportunity to file a Member Grievance. However, because the claims have never been received this option is not available to you. The only other option would be for Dr. Cook to submit a Provider Appeal. Under this appeal he would be required to submit the claims and all available information and request that the claims be considered for payment. If denied he would have to write the charges off.

BCBST regrets the claims were not received and benefits cannot be provided. However, we trust that you will understand why we must abide by all the terms, conditions and exclusions under our contracts. We also trust this information will be of assistance to you.

Sincerely, ,

Margie~ ( Sr. Coordinator
Legal Support Services (423) 535-3177


FRANKLIN ORTHOPAEDICS AND SPORTS MEDICINE, P.C.
PLEASE READ CAREFULLY AND SIGN WHERE INDICA TED

FINANCIAL POLICY

We are honored that you have chosen Franklin Orthopaedics and Sports Medicine for you care. Your orthopaedic health is our greatest priority. Of course, as with any business, we must reconcile our financial relationship as well. Patients have access to a variety of health plans, and our financial relationship is dictated primarily by the health plans that you, the patient, have chosen. Many of you have selected plans that have co-payments and deductibles, and it is our responsibility to collect those fees. In the wisdom of our legal system, it is actually considered fraud if we do not collect these payments. We appreciate your understanding that this is a necessary aspect of our relationship.

PAYMENT

Payment in full is due at time of service. This includes a!! co-pays, deductibles, and co-pay percentages. We accept
cash, check, Visa/Mastercard, Discover, and American Express. -

HMO REFERRALS

Referrals are the responsibility of the patient. If your insurance requires a referral, you must obtain one before being seen by the doctor. if a referral is required and you do not have Olle, you may rescheduie or elect to self-pay for services rendered. It is also your responsibility to make sure that you have a current referral for any follow-up visits. Please make sure this is taken care of before you arrive for your appointment.

INSURANCE -
~ase be advised that we file insurance as a courtesy. xpenses incurred at Franklin Orthopaedics and Sports Medicine are the responsibility of the patient, not the insurance ompany. Should your claim be denied, payment in full is due
iatel . Fr' i suranc y has not responded to our claim within 60 days from the date of
service, the entire balance will be transferred to you, the patient, for immediate payment.

UNPAID BALANCES

We will charge 1.5% interest per month on any unpaid balances as provided by state law. A $29.00 late fee will be charged for payments that are not made on time. There will also be a fee of $29.00 for all returned checks. In the event that this account is turned over to collections,to protect the interest of Franklin Orthopaedics and Sports Medicine, please understand that you will incur the cost of said collection, which will include reasonable attorney fees and court costs.

FRACTURE CARE

When a bone is fractured it usually bleeds. So bruising and swelling is common. Therefore, should you suffer a fracture, it is advisable to elevate the fractured extremity for at least 48 hours and longer if necessary. Placing an ice pack over the fracture is also helpful. Please keep your splint or cast dry and do not put anything inside of it. Call our office immediately if you are havinq severe increasinq pain, numbness or tinGlinG of your finqers or toes, or any other problem.

MEDICAL BILLING FOR FRACTURES

Medical claims can be very confusing. Should you suffer a fracture, the insurance company may require that you are charged what is called a qlobal fee at the initial visit associated with that particular fracture. This initial qlobal fee covers all follow-up exams for 90 days if they are associated with the same fracture.

However, you will be charaed separatelv for any diaqnostic procedures such as x-rays, and for actual treatment such as casts or splints.

Insurance companies often qroup and pay for fracture care under a cateGory they designate as "surqerV', even though actual surgery may have not been performed for a particular fracture. Therefore, don't be alarmed if you receive a mailing from your insurance company listing "surgery" even though a fracture you received care for required no surgery. In addition, fracture care, like surgeries are very often subiect to deductibles over and above any co-pay amounts.

-to health insurance plans increasinGly base their payment rates on what Medicare determines - not our fee schedule.

I have read and understand the above.

****I signed this agreement, why didn't you file the claim?????

My first inclination after reading the above complaint was to simply consider the source and therefore ignore these ramblings. After discussing with my attorney and further consideration of the issue, it is evident that the intent of her statements are purely defamation and therefore must be addressed. There are many half truths and inaccurate statements that could be addressed but for the sake of brevity, I will simply speak to the most pertinent points. So as not to violate any physician/patient confidentialities or to violate any HIPAA regulations, I will only refer to discussions had during the court proceedings that can be supported by documents from the court proceedings which are public record.

Ms. Ake-Coward fell in the parking lot of a Waffle House and then came to see me for treatment several days later. At that time, she presented us with the information from CNA Insurance which is the liability carrier for Waffle House and the company she intended to pay her bills. CNA did continue to pay her bills until they realized this would go to litigation and then they stopped paying the bills until this issue was ultimately settled. She alludes to having Blue Cross Blue Shield insurance coverage, and in fact, the coverage that she states we should have used to pay for her care was not even in effect until approximately 2 months after her fall. It is not possible for my office to file insurance on a policy that does not exist and we did file with CNA at Ms. Ake-Coward's direction.

On 2/21/05, Ms.Paulette Ake-Coward received a settlement statement from her attorney and she signed this settlement statement on the above date. The settlement statement reads "This is to acknowledge that Attorney Lance B. Mayes, has settled the above referenced case for a total settlement of $30,000. Attorney's fees totaled $10,000, which Mr. Mayes reduced to a fee totaling $7,000. I, Paulette Ake-Coward, am receiving $23,000 regarding said settlement and I am and will be responsible for any outstanding amount due or owing regarding medical bills, including said bills owed to Franklin Orthopaedics."

These facts with supporting documents, as well as many other supporting documents have been reviewed by two separate judges, in two separate courts, and both have ruled that Ms. Ake-Coward should pay her outstanding medical bills as she agreed to do in the settlement statement she signed on February 21, 2005. After the second judgment against Ms. Ake-Coward, she went back to court stating that she was unemployed and was unable to pay the settlement. The judge directed her to pay $30 per month over the next 3 months and to obtain a job. She then returned to court in December, 2007, having found a job. She was then directed by the court to make installments of $164. She is to pay that amount until the total settlement of $7,200 has been reimbursed.

In summary, Ms. Ake-Coward received excellent orthopedic care in 2003. She then received a settlement from Waffle House and CNA Insurance of $30,000 dollars from which she specifically agreed to reimburse Franklin Orthopaedics as part of that settlement. The issue has been reviewed by two separate judges and two separate courts both of which ruled against her stating that she must use the money that she was given to pay her bill to reimburse Franklin Orthopaedics for the services that she received. She returned to court in December, 2007, and was able to negotiate the payments of $164 per month so it will take approximately 3 1/2 more years for her to pay this bill.

Ms. Paulette Ake-Coward received a very large cash payment after falling down in a parking lot. Part of that settlement was specifically intended to pay for her medical care provided by Franklin Orthopaedics. She will not fulfill her obligation for at least 6 years after she received her settlement. I do agree with Ms. Ake-Coward and I quote from her last paragraph, "How can I get some justice here? I only want what is fair!"

My first inclination after reading the above complaint was to simply consider the source and therefore ignore these ramblings. After discussing with my attorney and further consideration of the issue, it is evident that the intent of her statements are purely defamation and therefore must be addressed. There are many half truths and inaccurate statements that could be addressed but for the sake of brevity, I will simply speak to the most pertinent points. So as not to violate any physician/patient confidentialities or to violate any HIPAA regulations, I will only refer to discussions had during the court proceedings that can be supported by documents from the court proceedings which are public record.

Ms. Ake-Coward fell in the parking lot of a Waffle House and then came to see me for treatment several days later. At that time, she presented us with the information from CNA Insurance which is the liability carrier for Waffle House and the company she intended to pay her bills. CNA did continue to pay her bills until they realized this would go to litigation and then they stopped paying the bills until this issue was ultimately settled. She alludes to having Blue Cross Blue Shield insurance coverage, and in fact, the coverage that she states we should have used to pay for her care was not even in effect until approximately 2 months after her fall. It is not possible for my office to file insurance on a policy that does not exist and we did file with CNA at Ms. Ake-Coward's direction.

On 2/21/05, Ms.Paulette Ake-Coward received a settlement statement from her attorney and she signed this settlement statement on the above date. The settlement statement reads "This is to acknowledge that Attorney Lance B. Mayes, has settled the above referenced case for a total settlement of $30,000. Attorney's fees totaled $10,000, which Mr. Mayes reduced to a fee totaling $7,000. I, Paulette Ake-Coward, am receiving $23,000 regarding said settlement and I am and will be responsible for any outstanding amount due or owing regarding medical bills, including said bills owed to Franklin Orthopaedics."

These facts with supporting documents, as well as many other supporting documents have been reviewed by two separate judges, in two separate courts, and both have ruled that Ms. Ake-Coward should pay her outstanding medical bills as she agreed to do in the settlement statement she signed on February 21, 2005. After the second judgment against Ms. Ake-Coward, she went back to court stating that she was unemployed and was unable to pay the settlement. The judge directed her to pay $30 per month over the next 3 months and to obtain a job. She then returned to court in December, 2007, having found a job. She was then directed by the court to make installments of $164. She is to pay that amount until the total settlement of $7,200 has been reimbursed.

In summary, Ms. Ake-Coward received excellent orthopedic care in 2003. She then received a settlement from Waffle House and CNA Insurance of $30,000 dollars from which she specifically agreed to reimburse Franklin Orthopaedics as part of that settlement. The issue has been reviewed by two separate judges and two separate courts both of which ruled against her stating that she must use the money that she was given to pay her bill to reimburse Franklin Orthopaedics for the services that she received. She returned to court in December, 2007, and was able to negotiate the payments of $164 per month so it will take approximately 3 1/2 more years for her to pay this bill.

Ms. Paulette Ake-Coward received a very large cash payment after falling down in a parking lot. Part of that settlement was specifically intended to pay for her medical care provided by Franklin Orthopaedics. She will not fulfill her obligation for at least 6 years after she received her settlement. I do agree with Ms. Ake-Coward and I quote from her last paragraph, "How can I get some justice here? I only want what is fair!"

My first inclination after reading the above complaint was to simply consider the source and therefore ignore these ramblings. After discussing with my attorney and further consideration of the issue, it is evident that the intent of her statements are purely defamation and therefore must be addressed. There are many half truths and inaccurate statements that could be addressed but for the sake of brevity, I will simply speak to the most pertinent points. So as not to violate any physician/patient confidentialities or to violate any HIPAA regulations, I will only refer to discussions had during the court proceedings that can be supported by documents from the court proceedings which are public record.

Ms. Ake-Coward fell in the parking lot of a Waffle House and then came to see me for treatment several days later. At that time, she presented us with the information from CNA Insurance which is the liability carrier for Waffle House and the company she intended to pay her bills. CNA did continue to pay her bills until they realized this would go to litigation and then they stopped paying the bills until this issue was ultimately settled. She alludes to having Blue Cross Blue Shield insurance coverage, and in fact, the coverage that she states we should have used to pay for her care was not even in effect until approximately 2 months after her fall. It is not possible for my office to file insurance on a policy that does not exist and we did file with CNA at Ms. Ake-Coward's direction.

On 2/21/05, Ms.Paulette Ake-Coward received a settlement statement from her attorney and she signed this settlement statement on the above date. The settlement statement reads "This is to acknowledge that Attorney Lance B. Mayes, has settled the above referenced case for a total settlement of $30,000. Attorney's fees totaled $10,000, which Mr. Mayes reduced to a fee totaling $7,000. I, Paulette Ake-Coward, am receiving $23,000 regarding said settlement and I am and will be responsible for any outstanding amount due or owing regarding medical bills, including said bills owed to Franklin Orthopaedics."

These facts with supporting documents, as well as many other supporting documents have been reviewed by two separate judges, in two separate courts, and both have ruled that Ms. Ake-Coward should pay her outstanding medical bills as she agreed to do in the settlement statement she signed on February 21, 2005. After the second judgment against Ms. Ake-Coward, she went back to court stating that she was unemployed and was unable to pay the settlement. The judge directed her to pay $30 per month over the next 3 months and to obtain a job. She then returned to court in December, 2007, having found a job. She was then directed by the court to make installments of $164. She is to pay that amount until the total settlement of $7,200 has been reimbursed.

In summary, Ms. Ake-Coward received excellent orthopedic care in 2003. She then received a settlement from Waffle House and CNA Insurance of $30,000 dollars from which she specifically agreed to reimburse Franklin Orthopaedics as part of that settlement. The issue has been reviewed by two separate judges and two separate courts both of which ruled against her stating that she must use the money that she was given to pay her bill to reimburse Franklin Orthopaedics for the services that she received. She returned to court in December, 2007, and was able to negotiate the payments of $164 per month so it will take approximately 3 1/2 more years for her to pay this bill.

Ms. Paulette Ake-Coward received a very large cash payment after falling down in a parking lot. Part of that settlement was specifically intended to pay for her medical care provided by Franklin Orthopaedics. She will not fulfill her obligation for at least 6 years after she received her settlement. I do agree with Ms. Ake-Coward and I quote from her last paragraph, "How can I get some justice here? I only want what is fair!"

My first inclination after reading the above complaint was to simply consider the source and therefore ignore these ramblings. After discussing with my attorney and further consideration of the issue, it is evident that the intent of her statements are purely defamation and therefore must be addressed. There are many half truths and inaccurate statements that could be addressed but for the sake of brevity, I will simply speak to the most pertinent points. So as not to violate any physician/patient confidentialities or to violate any HIPAA regulations, I will only refer to discussions had during the court proceedings that can be supported by documents from the court proceedings which are public record.

Ms. Ake-Coward fell in the parking lot of a Waffle House and then came to see me for treatment several days later. At that time, she presented us with the information from CNA Insurance which is the liability carrier for Waffle House and the company she intended to pay her bills. CNA did continue to pay her bills until they realized this would go to litigation and then they stopped paying the bills until this issue was ultimately settled. She alludes to having Blue Cross Blue Shield insurance coverage, and in fact, the coverage that she states we should have used to pay for her care was not even in effect until approximately 2 months after her fall. It is not possible for my office to file insurance on a policy that does not exist and we did file with CNA at Ms. Ake-Coward's direction.

On 2/21/05, Ms.Paulette Ake-Coward received a settlement statement from her attorney and she signed this settlement statement on the above date. The settlement statement reads "This is to acknowledge that Attorney Lance B. Mayes, has settled the above referenced case for a total settlement of $30,000. Attorney's fees totaled $10,000, which Mr. Mayes reduced to a fee totaling $7,000. I, Paulette Ake-Coward, am receiving $23,000 regarding said settlement and I am and will be responsible for any outstanding amount due or owing regarding medical bills, including said bills owed to Franklin Orthopaedics."

These facts with supporting documents, as well as many other supporting documents have been reviewed by two separate judges, in two separate courts, and both have ruled that Ms. Ake-Coward should pay her outstanding medical bills as she agreed to do in the settlement statement she signed on February 21, 2005. After the second judgment against Ms. Ake-Coward, she went back to court stating that she was unemployed and was unable to pay the settlement. The judge directed her to pay $30 per month over the next 3 months and to obtain a job. She then returned to court in December, 2007, having found a job. She was then directed by the court to make installments of $164. She is to pay that amount until the total settlement of $7,200 has been reimbursed.

In summary, Ms. Ake-Coward received excellent orthopedic care in 2003. She then received a settlement from Waffle House and CNA Insurance of $30,000 dollars from which she specifically agreed to reimburse Franklin Orthopaedics as part of that settlement. The issue has been reviewed by two separate judges and two separate courts both of which ruled against her stating that she must use the money that she was given to pay her bill to reimburse Franklin Orthopaedics for the services that she received. She returned to court in December, 2007, and was able to negotiate the payments of $164 per month so it will take approximately 3 1/2 more years for her to pay this bill.

Ms. Paulette Ake-Coward received a very large cash payment after falling down in a parking lot. Part of that settlement was specifically intended to pay for her medical care provided by Franklin Orthopaedics. She will not fulfill her obligation for at least 6 years after she received her settlement. I do agree with Ms. Ake-Coward and I quote from her last paragraph, "How can I get some justice here? I only want what is fair!"