The billing for this one has twists. I initially thought it only had one exceptionally troubling detail. Then I saw a second one. I was wrong both times. It has a mountain of 'them'.

I tried to communicate with them via chat and Blue Shield via phone.

• Those didn't go so well, as you'll see fully below. A real sham indeed.

On 9/20/2019, I faxed a letter to Dr. Rupp, the managing doctor for this practice.

• Click here for letter to Dr. Rupp
• It covers the info below in confusing detail, to return the confusion to its rightful owners.

Read the letter if you like, but don't let it scramble your head too much.

• If you feel that happening, read in less detail or stop reading that, and start reading below.

In summary:

• They included a $415 line item on my bill for a service that wasn't rendered and not relevant. And they did this twice.
• They indicated $415 was due from me as a non-covered item, after it was declined by insurance, twice.
• They provided conflicting instructions for the $415 item, saying it was pending insurance too, after saying it was due, when in fact it had been clearly been declined, twice, prior to the bill printing...
• They got paid almost twice the going rate for an MRI, excluding this $415 line item
• They may have been paid TWICE for the MRI !! (in addition to being paid almost double the rate). They may have achieved this by submitting a full bill twice that had no reason to be resubmitted, twice.
• They have created an incredibly confusing situation with their patient balance column and their amount due column, in addition to the manipulation above, and they presented this entire mind scrambling bill not once, but twice...
• They claim they are a Blue Shield contracted provider on their website, and that was assumed when the auth was issued with their name on it, but the bill doesn't reflect that. When a billing rep was asked that question in a chat room after being lead into a blind corner she didn't see coming, she silently left our chat without so much as a soft goodbye.

And it was then and only then I knew for sure this publishing was going to blow up and make a rather large splash...

The letter above asks for a written response from Dr. Rupp by Wednesday, October 9, 2019

• Get up to speed before this hops another step.

Let's start with the bills first to set the stage...

Line item 1

DOS: 4/22/2019 (73700) for $265

This item for $265 is for the "read" for a CT scan that was done at Salinas Valley Memorial Hospital. This bill only shows their Billed amount. It does not show any payments from insurance or adjustments even though the service was provided two months prior.

Thus, the $265 amount in the "patient balance" column is irrelevant and quite confusing. There should be no value in that column until the EOB comes back and adjustments are made.

(and yes, that part is quite confusing. There is no reason at all this value should be in something called a "patient balance column". It just creates confusion, which billers and insincere MD's like to use for manipulation. ).

Line item 2

DOS: 5/20/2019 (73220) for $592

($492 from B/S, $100 from me)

This line item is for an MRI with contrast on my left bicep area. Although this service was done a month after the simple 4/22 CT scan read (line item 1), per this has been billed, an EOB has been returned from B/S and adjustments to the bill have been properly applied.

Per this statement, they were reimbursed $492 for this MRI from B/S and my cost is $100. So their total revenue for this MRI (for the procedure and the read, which are often separate items) is $592.

QUESTION?! - SVMC Imaging is being allowed $237 for an MRI and another $80 is allowed for the read. So $317 is the going total for this type of service. Why are these folks getting $592 for the scan and the read? In fact they got another $80 for the contrast shot, so all in they got $672 for this service. The machine scanning after the dye shot was about 5-7 minutes added on to a 30-40 minute process and it seems the total adder for a contrasted MRI is about $75-125, still leaving a massive premium for this company for some reason. B/S indicated they must have "negotiated" those special rates. What does a MD office have to say or do to get paid double the folks across the street?

Line item 3

DOS: 5/20/2019 (76377) for $415

YIKES!? This says "PROCEDURE IS NOT COVERED BY YOUR INSURANCE. PLEASE REMIT PAYMENT?!! "

OMG. I didn't get to pick this vendor. Surely B/S didn't force me to go to an out of network provider did they?

To add to the confusion... the asterisks aligns with a note that says "insurance pending", so that makes this more confusing.

Is it not covered and due, or is insurance pending? There is no mistaking the command.

And my gosh, how much more money could they want? They already got paid $672 for approximately 45 minutes of work by a technician and 10 minutes of reading by a radiologist?

Line item 4

5/20/2019 (A9585) for $80

($68 from B/S, $12 from me)

This line item is for the die injection shot for the "contrast". That seems like a lot of money for an injection for die. And for what it's worth, the total scanning time after die was injected was maybe 5-7 minutes. Doing and MRI with Dye is not a huge deal and when they get paid $80 to administer the shot, that's a lot in and of itself.

!!Important Side Note!! The physician prescribed and MRI WithOUT contrast. The imaging company scheduling person forced the MD to change his order to a slightly more expensive and time consuming procedure at time of processing the order.

There are confusing issues with two of the four line items, and one is very nefarious.

There are seemingly over reimbursement issues ( and they likely got paid twice on top of that as you'll see below)...

$672/hour is approximately $1.34 Million annually for a 40 hour work week for one imaging technician, one imagining machine, one front desk person and 1/6th of an MD (assuming they can do reads and reports in 10 minutes).

How much do these people feel they should make?

I try to avoid paying a bill until all outstanding items have been adjusted. Doing anything else typically gets far more confusing. Nefarious billers and insincere doctors know that, so they love to bill partials for starters. I also won't pay a bill with conflicting demands for amounts due on it, and certainly not one that intimates I, as an in-network patient should owe for a non-covered service, which I was assigned to the imaging center by my insurance company.

Thus, I didn't pay anything. I just waited to see if they would self correct...

IMPORTANT NOTE: When an MRI is authorized, it is authorized for a body part AS WELL AS a provider!! The approval authorization letters sent to the patient imply they have a choice of vendors. That is fully false impression.

This MRI was approved first for SVMC Imaging (the inhouse provider at my doctors office). They had a 3 week wait.

I called Salinas Valley Imaging, which is right across the street and they had availability within a few days, BUT I couldn't use my authorization with them. They had to start the authorization process all over again with my doctor.

Once we got the authorization worked out, Salinas Valley Imaging had a few day wait, and I was trying to get it done quicker so it was done in time for an appt with my doctor. Salinas Valley Imaging also owns Coastal Valley Imaging in Carmel, CA, and they got me in there the next day.

As suspected. This is where the nefarious games get better... But what on earth did they really do?

Why have they included a non-covered item on both bills with a demand for payment that is not included in the total amount box?

The billing company website is in the bottom left corner of the bill.

Yes. These billers do appear to be "professionals" for sure, but likely not in the way most are imaging right now, and likely not in a legal sense either...

Comment: This EOB does NOT clearly state whether this service provider is in network or not. Why hasn't Blue Shield made that extremely relevant fact transparent on all their EOBs?

Comment: This EOB It does state "exclusive provider" -- What is that? I called and asked. B/S rep indicated it means the provider is related to the facility. That doesn't however make sense because it shows up on the SVMC imagine reads where the Radiologists are seemingly 200 miles away and unrelated. Also, why the heck include this on an EOB and not the "network status", which is far more relevant to a consumer/patient/pig for the slaughter in this hellish process?

Comment: This is a very flawed statement (EOB) by B/S and it can only have been designed with that intention. This statement doesn't give clear indication of network status. Note 1 at the bottom is incredibly inappropriate. It opens up the consumer to the idea that non-covered items might be their responsibility even though there is no network status flag on this EOB and there are seemingly no non-covered items on this bill if you look closely at the columns. How many decades has Blue Shield been in business? If the goal was transparency, could they have created a transparent statement by now? Where exactly are most of B/Shieilds call centers located? (The Phillipines...)

This biller feels/thinks it would hard to legally charge them with billing fraud in this case because they can claim they were sloppy with billing and it was all just a "mix up" (negligence at best, in their mind). A review should be done of all bills sent out in the past few years. See how many "mixups" there were and see how much they brought in from those...

There is a high likely hood that this EOB was paid twice. It would be worth checking for sure. Also, ask B/S why the notes didn't indicate previously billed...

This is very, very odd and disturbing... very disturbing. Why would Blue Shield leave a door open for non-covered service billing manipulation like this?

The insurance companies have made it easy for billers and physicians to commit fraud. Some of us believe there are inside deals being struck between insurance employees and providers and this exposes what that might look like.

So far..

This company billed for non-covered services and asked for payment, while confusing things a lot to provide a negligence cover for fraud.

Blue Shield's EOB doesn't fully clarify the disposition of that faux line item and doesn't clearly state network status, the single most important fact on any EOB.

This company has been reimbursed almost twice the amount for an MRI as compared to others

This company may have been reimbursed 2 times for the total billing. The fact that the EOB was not returned with "duplicate bill" on it is not proper protocal and the adjustments on bill two would be what is required to get a second payment into the accounting system.

I called the billing company today and got vm. They provided their website address (www.msnllc.net and an email address of customerservice@msnllc.com . (website is .net and email is .com)) I submitted an email asking about the $415 fee and am waiting on a response back.

I also entered a chat forum and started asking questions. Most people behaving in an appropriate manner don't drop a chat dialogue after I ask a simple question like "am I an in network patient? " When that gets done after a 30 minute setup however, fraudulent billers know when to drop the dialogue..

At what point can we talk about billing fraud in interstate commerce?

I called 855-836-9705. Spoke to "Stella". Pretty good English. Sounded like a far east accent. I believe their call centers are in the Philippines (per someone who sets them up...).

1) The $415 charge was declined on both EOBs as shown. Supposedly B/S sent out a request for a "blood bank receipt" which would be required to process the $415 item. She said they had heard nothing back from the provider. When asked about the CPT code which looked more like a computer imaging thing, she said it was for 3d imaging. When I asked how a blood bank receipt was relevant for a 3d imaging CPT code, she started bouncing around. She couldn't make any connections. There was time away from the phone....

2) I asked her if my EOB indicated my network status anywhere. All she had to do was look at a pdf of any of my EOBs. After 5 minutes away, she confirmed the EOB does NOT specify if the provider is in or out of network. A simple question that she tried very hard to avoid to answer... and this is Blue Shield's primary customer support line??

3) According to her, the term "exclusive provider" indicates the service provider was related to the facility...(which kind of makes sense given it's the radiologists billing for the facility too, but it doesn't because the billers from Novato are noted that way on SVMC bills).

4) She was not able to clarify the premium that was paid to this company for an MRI vs SVMC imaging. She confirmed the 73220 was upper left side extremity.

5) She couldn't clarify why the Note 2 wasn't clearer indicating that was not an item I'd need to pay for. She did say don't pay the $415 and that was fast and clear, which was equally odd, given her inability to clarify all the other stuff...

Ask yourself a few simple questions... 1) Why isn't there a clear note on the EOB declaring in or out of network provider and 2) ask yourself why note 2 clearly states "do not represent covered services" yet the "non-covered" column for line item 2 shows 0 instead of $415. They leave the doors open for manipulation, and it's not accidental. It's consistent.

Are some of the medical providers in the US in cahoots with someone who's doing statement configuration for Blue Shield, with overseas telephone agents in on the game? I don't know how else to sum it up. As far fetched as this sounds, do you have a better explanation? All this "sloppiness" doesn't happen organically.

I will not pay a bill riddled with demands for payment for items that are not mine to pay, so I waited,

This is the bill that came next. This doesn't clarify that $415 line item. I don't know if that's still pending out there in the ether or not and I'll need to get that addressed in writing before I pay this bill. The second page of this implies I may have been turned over to a collection agency? Hum. That won't have been a wise move...

I'm drafting a rather hot letter now. They will wish they had diverted when they had the chance...

Contracted Insurance Plans -- Blue Shield listed clear as day...

9/16/2019 -- Called to get Name of Managing MD and proper mailing address for communication. Left message for supervisor Natalie Alvarez.

TBC...

Finalized publishing 6/18/2020...

I wrote this to Doug. He replied in red. I was trying to force him to take money the bill clearly said I owed, hoping he would hang on to it for some reason, as there is no lawsuit if he doesn't have money that is not owed to him. All of this manipulation is 'legal' in the US system of commerce...

On October 25, 2020 I had a full and clear understanding of my Bill. To prove a point, I logged into the billing system for this radiology clinic and engaged them in a chat dialogue and what transpired was the "ode to inversionistas"...

And this is what transpired...

https://docs.google.com/document/d/1eqwAbtBD4wcsnVF2QPrr4yHNbw5C18zBvmgpe5H8gDY/edit?usp=sharing

Doug never knew I logged into his billing system on 10/25 and picked up a dialogue with his crooked folks out of Georgia who contradicted everything he said.

This is the utterly corrupt billing system for 150 of the largest radiology clinics in the country. The head of this particular snake resides at 2790 North Academy Blvd, #229, Colorado Springs CO 80917.

Now he does...