AccountId: 011433970860
ContactId: 9be5e601-78a4-489b-90f7-046873e0af2f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1071530 ms
Total Talk Time (AGENT): 464090 ms
Total Talk Time (CUSTOMER): 476252 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/9be5e601-78a4-489b-90f7-046873e0af2f_20250403T17:41_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Well, hey Miss [PII], it's [PII]. How are you?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][NEUTRAL] Well, I'm fine. I have an insured on the line who had received a voicemail. It looks like it was from [PII].
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Today on a hub ticket and [PII] left her a voicemail um and she does have some additional questions because she's the OK, let me give you the policy first.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 156
[CUSTOMER][NEUTRAL] 8608.
[CUSTOMER][NEUTRAL] For Ms. [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The data service she's calling about is 11-17-23.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the amount, uh, it would be on claim number 3500111.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And she is stating that that doesn't make sense because she was not there 24 hours. She was at home.
[AGENT][NEUTRAL] On [PII] 2023.
[CUSTOMER][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] OK, give me one second.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] She said she went and had her procedures. She was there for a few hours and went home.
[AGENT][NEUTRAL] 1:17.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] I'm sorry, I talked to myself.
[CUSTOMER][NEUTRAL] That's OK, [PII]. I do too.
[CUSTOMER][POSITIVE] Uh, I do too. It keeps me, it keeps my feet on the ground at times. It's OK, no judgment here.
[AGENT][NEUTRAL] It does and so online lip so she said she had.
[AGENT][NEUTRAL] What date was it on?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII], [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And I looked at Misty's notes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEGATIVE] You know, she's the, the lady said she was it, that doesn't make sense. She was at home.
[AGENT][NEUTRAL] Let me pull this up. um, I'm just trying to get everything pulled up and I'm gonna let you send her over to me.
[CUSTOMER][POSITIVE] Yeah, sure. No, that's yes and uh thank you for your help.
[AGENT][NEUTRAL] It looks like we have a hospital bill and a facility.
[AGENT][NEUTRAL] I'm just trying to look at both of them, see what we got 3.
[CUSTOMER][NEUTRAL] Sure. Mhm.
[AGENT][NEUTRAL] Most people try to say well yes I was there over 24 hours.
[CUSTOMER][NEUTRAL] Right, and this like that's what she said I've not been inpatient since I had my baby over 31 years ago.
[AGENT][NEUTRAL] Oh, OK. I can explain it to her cause she was there, she was in observation. They did 24 hours of observation, so that's over 18 hours.
[CUSTOMER][NEUTRAL] Right, but she said she was not there that long. I went over that part with her again, but she said she was not there anywhere near that long. She was at home. She wouldn't have a procedure, stayed a few hours and went to her house.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, alright, you can send her on over and I'll try to talk to her.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] OK, [PII]. And I'm making up my, I'm making my note now. So thank you so much.
[AGENT][POSITIVE] OK. No problem. Have a great one.
[CUSTOMER][POSITIVE] All right have a good afternoon.
[AGENT][NEUTRAL] You too.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling. I am calling. I, I don't know if the lady that transferred me gave you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The story did she explain why, why I was calling?
[AGENT][NEUTRAL] Yeah, she said that uh uh you were calling because you had spoke to someone else uh they had left you a voicemail and you was calling them back uh but she stated that you were not there over 24 hours.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I, I was not. I had surgery, outpatient surgery. I was there just in the recovery room and then I was sent home.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But they're rejecting a claim saying that I was in the hospital overnight and
[CUSTOMER][NEUTRAL] As I explained to her, I have been in the hospital overnight in many years.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I said do you know approximately how long you were there?
[CUSTOMER][NEUTRAL] I believe about 3 hours. I don't remember how long the surgery was, but after the surgery, they
[CUSTOMER][NEUTRAL] You know, just get you up.
[CUSTOMER][NEUTRAL] And then you go home. So, I wanna say I was home.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] By 3 or something like that. I don't remember exactly.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so you went in on the [PII] that morning on the [PII], is that correct?
[CUSTOMER][POSITIVE] Yes, yes, I did.
[AGENT][NEUTRAL] OK, alright, so, uh, when we process the claims we do have to process them according to the way the provider bills and so they billed it with 24 hours.
[AGENT][NEUTRAL] Um, of observation and so for us we consider that inpatient.
[AGENT][NEUTRAL] Um, I do have to advise though your if we, uh, your inpatient benefit is more than your outpatient, uh, if you want us to consider it under the outpatient benefit we would need the admin and discharge times.
[AGENT][NEUTRAL] Uh, and once we do that, if we determine that you were there under 18 hours, uh, we would have to request most of the money back because your outpatient benefit is only $750 per calendar date.
[CUSTOMER][NEUTRAL] For the anesthesiologist?
[AGENT][NEUTRAL] Uh, that would be for everybody. We would, so, uh, the, so we would, uh.
[CUSTOMER][NEUTRAL] That's
[AGENT][NEUTRAL] If you uh if you want to want us to consider under the outpatient benefit we can do that.
[AGENT][NEUTRAL] Uh, we would just need something showing that you were there.
[CUSTOMER][NEUTRAL] But it should be considered under what actually happened. If I wasn't in there and the claim was put in and properly, it should be put in correctly.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so we process it according.
[CUSTOMER][NEGATIVE] However, when it turns out, I'm, I'm not gonna tell you to leave it there incorrectly when they're sending me a bill because they're saying, you said I exceeded my inpatient benefit. I've never had an inpatient stay in the hospital, so I don't even see how you could say that.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, alright, so, uh, like I say, your policy states that if you were there over 18 consecutive hours, and I know you said that you were not.
[AGENT][NEUTRAL] But the way they build it
[CUSTOMER][NEUTRAL] I was at the, yeah, I've never been there over 18 hours.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So in order to correct the, the inpatient benefits we would need the admin and discharge times from the hospital. So if you can get that information for us and you can send it in and we can go back and look at.
[AGENT][NEUTRAL] That information, the new information you sent in, then we could adjust it.
[AGENT][NEUTRAL] But like I stated, being that your outpatient benefit is only $750 per day and that would be, you know, hospital, the surgeon, the anesthesiologist, whoever. And so we're still not gonna be able to pay the uh the, the anesthesiologist charges because that benefit for outpatient is only $750.
[AGENT][NEUTRAL] And so that's probably the hospital is probably gonna eat up.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] But I have a, I have, OK, I'm not understanding because you wouldn't be paying.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] The, this is just the gap coverage, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] I have insurance for the actual.
[CUSTOMER][NEUTRAL] Surgery with Aetna Insurance Company, this would be just whatever exceeded that, I guess.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see, let's look at one of your.
[CUSTOMER][NEUTRAL] So I'm not understanding why you why you're saying that because you wouldn't have been responsible for the primary deal.
[AGENT][NEUTRAL] OK, so let's see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So for the, for the hospital stay, I mean for the hospital charges.
[AGENT][NEUTRAL] But are the facility charges for that day?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Your primary insurance carrier applied $3,468.90 to your deductible.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that's what APL picks up of your deductible. So if we uh had processed this claim.
[CUSTOMER][NEUTRAL] No, I
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEGATIVE] No, no, that's not. I actually paid that myself.
[CUSTOMER][NEUTRAL] The day I went to the hospital, I paid the deductible part.
[AGENT][NEUTRAL] OK, because we also sent them a uh payment.
[CUSTOMER][NEUTRAL] I had to take out
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And so we also sent them a payment.
[CUSTOMER][NEGATIVE] Well, can you explain to me what, what the issue is because now here it is a whole, almost 2 years later, I'm getting an invoice from anesthesiologist saying that they weren't paid.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] So, is it the way they build, build it to you or what is the problem? I can't figure out why this is happening in the first place. I've had two surgeries prior to this and I didn't have this issue, so is it something that was billed incorrectly? Do I need to go back to them and see how they.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It coded it or something, what's the problem?
[AGENT][NEUTRAL] No, ma'am. No. Uh, the problem is, uh, there's really not a problem because as I stated, for that procedure you had on [PII], they billed it.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That you have that you were in observation for 24 hours, however, you're saying that you are not, but that's how they build it.
[CUSTOMER][NEUTRAL] Right, I was.
[AGENT][NEUTRAL] OK, so, but per your policy from what we received, we, we processed it under the out the inpatient benefit because it says you were there 24 hours, so we process it under your inpatient benefit. Your inpatient benefit pays up to $3500 per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, for the, the charges, the charges that you had for uh that surgery, we paid $3400 but $3468 90s to the hospital. And then there was some other liberty charges that we paid and that maxed out the $3500 benefit for inpatient for the [PII] calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So when the anesthesiologist charges came in, there were no additional benefits for
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] To pay the anesthesiologist because we had paid out the $3500 that we allow.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright because I just wasn't understanding why they're saying so.
[CUSTOMER][NEGATIVE] That that wouldn't be paid because of inpatient and I.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I knew that it was an outpatient surgery. So that's where I'm getting confused. Like why are they coding it as inpatient when it was outpatient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, because the hospital, uh, the way they build it.
[AGENT][NEUTRAL] Uh, that you were there over 18 hours.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And so that's how we have to process it that way.
[CUSTOMER][NEUTRAL] OK, I'm gonna just talk to the administrator at work because I, I don't understand it.
[CUSTOMER][NEUTRAL] OK, well.
[AGENT][NEUTRAL] OK, but like I stated, if you do, if you do, if you, um.
[CUSTOMER][NEUTRAL] I guess
[AGENT][NEUTRAL] Do you want to send in documentation showing that you were there, that you were not there 24 hours?
[CUSTOMER][NEUTRAL] Well, I'm gonna have to go back and find or go back to them and see if they have records of my stay from [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I, I mean I could check. I don't know that they would. I, I maybe I have something at home in my file. I'll check and see. It should tell the discharge time.
[AGENT][NEUTRAL] Where is
[AGENT][NEUTRAL] Yeah, yeah, that's what we would need to know what time you were admitted to the hospital and the time that you were discharged, but like I stated, your outpatient benefit is considerably lower than the inpatient benefit so we would have to request refunds of those monies that we've paid out everything except $750.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I'll um.
[CUSTOMER][NEUTRAL] OK, I'll just discuss it with the the administrator and see.
[AGENT][NEUTRAL] OK, and um.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, was there anything else I can help you with Ms. [PII]?
[CUSTOMER][NEUTRAL] No, no, that was it. I just didn't understand why, you know, I was being told I had inpatient care when I had outpatient. That's the confusing part about it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But you just explained to me that may perhaps they build it that way because well that still is not I mean because.
[CUSTOMER][NEUTRAL] My primary carrier would be the one they'd be billing and then I, I don't know.
[AGENT][NEUTRAL] Well, being that, you know, being that they do do your primary first. And so being that we are secondary and we pick up your deductibles. So, you know, whenever you go in, you shouldn't have to pay your deductibles because that's what we pick up your deductibles and co-pay for any, you know, outpatient inpatient and outpatient services.
[AGENT][NEUTRAL] And so that's where APL comes in with make our payment.
[CUSTOMER][NEGATIVE] But see that, and that's still, I mean, it's not because I actually had to, to take out a credit card with Caredit to pay what I thought was supposed to be the deductible part. It was over $3000 for that. So now you're telling me there was none of this is making any sense to me.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Well, I would say contact the hospital.
[CUSTOMER][NEGATIVE] This is, this is the part that, you know, when I got there that morning, this is the part that won't be covered by insurance. And in fact, I think it was $4000. I had to take out a credit card to pay for that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Have you
[AGENT][NEUTRAL] Have you tried contacting them to see if there was an overpayment on your uh on those charges?
[AGENT][NEUTRAL] To see if there's an overpayment.
[CUSTOMER][NEUTRAL] No, the first, this is the first I'm hearing that there's even an additional charge for the anesthesiologist. Like I said, I'm just now getting emails that I have a balance with the anesthesiologist for $392 I believe.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's what this, what prompted the phone calls is because I thought I had taken care of all that with the care credit card, primary care insurance, and then secondary.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, well, one more question.
[CUSTOMER][NEUTRAL] And then this additional bill is being sent to me now.
[AGENT][NEUTRAL] OK, so when you, when you made the payment with the care uh Care Now card, uh, so was that for the hospital charges or the, the surgeon's charges?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] It was in a surgical center and that's where I had, that's who I had to pay. I was never in the hospital. I was in a surgical center.
[AGENT][NEUTRAL] The surgery center?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And which is across the parking lot from the hospital.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, because we, because we paid the 346,890 to the hospital, so, uh, you may want to contact them to see if there was an overpayment on your account.
[AGENT][NEUTRAL] And you know if there was then they you can probably try to see if they can um.
[AGENT][NEUTRAL] Uh, you know, if, you know, if you do a refund for the amount that you pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, because we did pay that amount that was applied to your deductible.
[CUSTOMER][NEUTRAL] Alright, I'll, I'll check.
[CUSTOMER][NEUTRAL] Well, that seems OK I'll look into it, but it just seems.
[CUSTOMER][NEUTRAL] Like a lot if I had to pay that before I could even get the surgery.
[AGENT][NEUTRAL] Yes, ma'am. Right.
[CUSTOMER][NEUTRAL] And then.
[CUSTOMER][NEGATIVE] And and then now almost 2 years later I'm getting a bill oh we never got paid.
[AGENT][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Because they said you're, you know, that's just crazy. OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Well, thank you for explaining that to me.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] No problem, but if you need any other assistance, you know, just feel free to give us a call back.
[CUSTOMER][POSITIVE] OK, all right, thank you.
[AGENT][POSITIVE] Alright, you have a great rest of your day, Ms. [PII]. Thanks for calling APL.
[CUSTOMER][NEUTRAL] You too bye. OK, bye.
[AGENT][NEUTRAL] All right, bye bye.