Made a Mistake With A Client. I Need Advice.

AllenChicago

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Hey all,

I made the mistake of telling a brand new client that his doctor was in the PHCS network, which meant that his annual physical would be free with Standard Security Life.

Turns out that that are two (unrelated) doctors with the same un-common last name in the same zip code. His doctor is NOT the one in PHCS.

Bottom line is that it is my fault and the client wants me to reimburse him for the $400 he had to pay his doctor for his annual December physical.

Should I proceed with helping him file a claim against my E&O policy, or should I simply pay him $400 and chalk it up as a lesson to be more thorough? I've never had an E&O claim in my 23 year career, but then again, I've paid premiums for all these years as well. ADVICE????

Thanks in advance for any constructive guidance...

-Allen
 
Re: Made a Mistake With A Client... Advice?

Hey all,

I made the mistake of telling a brand new client that his doctor was in the PHCS network, which meant that his annual physical would be free with Standard Security Life.

Turns out that that are two (unrelated) doctors with the same un-common last name in the same zip code. His doctor is NOT the one in PHCS.

Bottom line is that it is my fault and the client wants me to reimburse him for the $400 he had to pay his doctor for his annual December physical.

Should I proceed with helping him file a claim against my E&O policy, or should I simply pay him $400 and chalk it up as a lesson to be more thorough? I've never had an E&O claim in my 23 year career, but then again, I've paid premiums for all these years as well. ADVICE????

Thanks in advance for any constructive guidance...

-Allen

Silly question but do you really have an E&O policy with a deductible below $400? Before I paid I would want something in writing so the client doesn't come back to the well every year he wants to do an annual physical..
 
Re: Made a Mistake With A Client... Advice?

First, that sucks!

I would never, ever help them file the claim. Honestly, were they to even file suit I think you would win; bigger question is whether or not that would affect your licensing/appointments. Now, did you make a mistake? I think the answer is yes. Is it a large enough mistake that you should have to pay for his $400 office visit? I don't have all the facts so it's difficult to say, but some questions I would have are:
Did the client give you the first name of the doctor?
More importantly, did the patient check with the office before switching or receiving services? Provider directories are NEVER 100% current and changes happen all the time. Now had the client called you before they went for their visit and screamed bloody murder about the physician not being in the network before receiving services and could not switch out of his plan, that would be a different discussion.

This is definitely one of those situations where I don't think anyone can give you a clear right or wrong answer, but were I in your situation I would start reminding clients that provider networks change frequently and that they should always check with their provider before changing plans or receiving services. If you did tell them that provider directories can change and/or to check before receiving services, then I would put the blame 100% on the client. If you didn't advise them of that then I think it's a gray area, if you told him (which I doubt) that his doctor is in the network and will always be in the network then I would see his point better.

Regardless of what you decided to do, I would try talking to the carrier and explain the misunderstanding and see if they'll push it through anyway. Might not work, but it's worth the phone call.

My sympathy for you though, it always sucks to have a client upset even if it wasn't your fault.
 
Re: Made a Mistake With A Client... Advice?

This is also partly the doctors office mistake. Did they inform the client that they did not accept his insurance? or that it would be out of network?

Call the carrier, they may go ahead and cover it. Call the doctors office, explain the situation, see if they will at least split the cost with you. See if you can get the doctor to enroll with the carrier on the plan.

In the end, write the check.

Dan
 
Re: Made a Mistake With A Client... Advice?

Thanks for the helpful and insightful replies gentlemen.

I had no idea that my NAPA E&O had a deductible! I just renew it every year and send the certificate of coverage to the insurance carriers that require it. LOL...I suppose that since virtually every other insurance policy has a deductible, E&O would be no different. Thanks for this!

The insurance company told me that the ultimate responsibility lies with the client to read their policy...which plainly says: "Out-of-Network wellness charges are applied to the out-of-network deductible." However, if the client trusts what the agent (me) told him, I must bear some responsibility for my error. Sure, I could give this client the official line of "You should have read your policy carefully, I won't pay you the $421.00." Why would we even need E&O for health insurance sales if we could always point to the policy to clear ourselves?

I tried the route of getting the insurance company to pay some of it, but even the mid-level billing dept manager I talked to couldn't do so, because its computer driven, based on billing codes... or something to that effect.

I'll find the policy online and see what the deductible is. If it's more than a couple of hundred dollars, or if filing a claim is a "big f-ing deal", I'll just pay the $400 to get this behind me. This client and his wife purchased 4 policies from me in September 2010 (I sell health as a bene package)and are a very nice 50'ish year old couple.

Thanks again for the replies, information and guidance my colleagues!

-Allen :biggrin:
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This is also partly the doctors office mistake. Did they inform the client that they did not accept his insurance? or that it would be out of network?

Call the carrier, they may go ahead and cover it. Call the doctors office, explain the situation, see if they will at least split the cost with you. See if you can get the doctor to enroll with the carrier on the plan.

In the end, write the check.

Dan

Hey... calling the Doctors office to see if they will split the cost with me is something I hadn't thought of. Thanks Dan!

BTW...this client has gone to this doctor for his annual December physical every year since the late 1990's. He's had Blue Cross all that time. I told him that the doctor was in PHCS, so he'd pay $0 for his physical this year. (This was back in 08/2010) Client was happy and I was happy...until he called this week to inform me that the health insurance company would not pay for his physical.
:swoon:
 
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Re: Made a Mistake With A Client... Advice?

Should I proceed with helping him file a claim against my E&O policy,

Are you out of your God forsaken mind?

Why would you even CONSIDER for one millisecond doing something so asinine? Wow.....if someone wants to shoot you are you gonna cock the trigger too?

I'd give him $100, apologize and tell him to stfu about it.
 
Re: Made a Mistake With A Client... Advice?

BTW...this client has gone to this doctor for his annual December physical every year since the late 1990's. He's had Blue Cross all that time. I told him that the doctor was in PHCS, so he'd pay $0 for his physical this year. (This was back in 08/2010) Client was happy and I was happy...until he called this week to inform me that the health insurance company would not pay for his physical.
:swoon:

Paying him the $400 is not just a matter of paying him the $400, someone could consider that rebating or a variety of other issues, particularly because this amount was paid against his deductible. Is it likely to be a problem? No, but this whole thing shouldn't have happened in the first place and bad news comes in threes (so they say).

Also, for all you know, the doc WAS in the network and then went out.

I have to also completely agree with Dan that it's shame on the docs office for not verifying coverage, but I'm much harder on the member. For a number of years I worked as a carrier rep for MA companies and I would always train agents to call the doc to verify they accept it before having someone enroll because you never ever ever know. Sometimes the docs office takes the insurance, but claims they don't because they aren't up to date. That gives everyone a chance to clear it up BEFORE there is a claim. I ***hate*** to point the finger of blame at seemingly good agents, but I would partially blame you for not making that clear to them. Ultimately the provider networks can and do change almost daily, so anyone going to seek services without verifying the doctor still accepts their coverage is being at least slightly irresponsible.

Going back to the part where you're considering paying him for the office visit, I think you're most likely setting yourself up for more risk that way. E&O isn't for $400 claims (the deductible is probably at least $500, if not higher. Personally I would have a $10,000 e&o deductible if they would let me, because it's for much more serious issues. Let's say you made this mistake of guaranteeing someone coverage who then cancelled theirs, sadly was diagnosed with cancer a few weeks later, and then the carrier calls it a pre-exisiting condition and denies their claims for a total of $250k and counting. Guess what, that's why you have your e&o.

After considering this more, admittedly much less than you, I would suggest your course of action be to potentially apologize profusely for the misunderstanding and then suggest (as Dan brought up) that we play the "blame the provider" game. If they already have his money then it will be tough to get it back, but they honestly botched up too. With respect to paying him the $421, I would use the *legitimate* line, "I'm truly sorry for what happened and I apologize for the inconvenience, but I'm legally prohibited from paying you for that claim because it was applied to your deductible. The laws are very specific about that and I would be risking my license by doing that. I would then point out how much he saved or whatever incentive there was to switching and focus on the strong points of why he/they made the decision to switch. Educating the client about the way provider networks can and do change on a regular and frequent basis may also help ease the the clients anger/frustration. The fact of the matter is that you did make a mistake that almost anyone could have, the client and the provider made mistakes that are much more severe.

Hope this helps. As I said before, I hate it when a client is upset whether or not there was actually any wrongdoing.
 
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Re: Made a Mistake With A Client... Advice?

I do not think paying the $400 in anyway can be considered rebating. A mistake was made he can own up or not. I have had similar things like this on the P and C side happen...I paid. My E and O deducible is 5k!

By the way I had a client file a complaint against a producer that works for me and a carrier. This was over a policy refund that the insurance company refused to issue. (long story) well I met with the insurance dept and his suggestion was that I refund the client. I refused simply based on principal we actualy did everything we should have...and I knew it.
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Going back to the part where you're considering paying him for the office visit, I think you're most likely setting yourself up for more risk that way. E&O isn't for $400 claims (the deductible is probably at least $500, if not higher. Personally I would have a $10,000 e&o deductible if they would let me, because it's for much more serious issues. Let's say you made this mistake of guaranteeing someone coverage who then cancelled theirs, sadly was diagnosed with cancer a few weeks later, and then the carrier calls it a pre-exisiting condition and denies their claims for a total of $250k and counting. Guess what, that's why you have your e&o.

X2 don't even think anymore about filing a claim!
 
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Re: Made a Mistake With A Client... Advice?

Seems to me the Dr.'s office is the one at fault. When your client went to their Dr. appointment (or set their Dr. appointment over the phone), the Dr.'s office verifies your client has insurance, etc., basically finding out how they will be paid before services are rendered. At that point everything would have been discovered and there would be no surprises. Blame the Dr.'s office for this mishap.

Whenever I go in for a physical, etc. I'm ALWAYS asked to show my BCBS card to the girl behind the desk, before the Dr. sees me.

Even if you were wrong about this Dr. being in the network, the Dr.'s office should have noticed this right away before the physical was performed.
 
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