AccountId: 011433970860
ContactId: fa24ddc7-990f-4d09-8459-67722ab785b4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 464440 ms
Total Talk Time (AGENT): 222650 ms
Total Talk Time (CUSTOMER): 292570 ms
Interruptions: 10
Overall Sentiment: AGENT=1.7, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/fa24ddc7-990f-4d09-8459-67722ab785b4_20250402T21:04_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], my name is [PII]. I am calling from a provider's office again. I called a couple days ago and our patient seems to think that one of us have misunderstood what her benefits are, so I just need to re verify what kind of coverage she has with your plan.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, OK, yeah, we can review those benefits, um, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, I'm at area code [PII] and my extension is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. Did you have that policy number?
[CUSTOMER][NEUTRAL] It's 1462947 and she is [PII].
[AGENT][NEUTRAL] OK, did you have her date of birth?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] Perfect. OK, thank you for verifying that. Um, so yes, of course, the policy is active. Uh, effective date was [PII]. I'm sure you already know this, but, uh, as this is a secondary medical policy, in short, is, it is designed to help with co-pay, deductible and co-insurance after major medical pays. Uh, what kinds of benefits are we looking at? I'm sorry.
[CUSTOMER][NEUTRAL] OK, that, that
[CUSTOMER][NEUTRAL] That might be the that might be where the description is. Does it help with this after the patient has met her deductible or before?
[AGENT][POSITIVE] It helps with it so what we need for these kinds of claims is um.
[AGENT][NEUTRAL] Of course the itemized statement showing diagnosis and procedure codes and then the explanation of benefits primary insurance, um, so if she has not yet met her deductible, uh, this the benefit amount for she has a benefit for inpatient and then outpatient services and that is what all of that goes towards to help with primaries, uh, co-pay, deductible, and then co-insurance.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah, she, I, I called, yeah, I called and talked to [PII], and she said that the um the plan pays for the deductible, co-pay, and co-insurance after the primary insurance has been filed, so this patient has called us 3 times today. She's driving us crazy. She says she was told.
[AGENT][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] She wants to know what her how much her copay would be for an office visit because she doesn't have a copay with Blue Cross. She has a deductible that she has to meet and I told her my understanding, my understanding was that as long as American public life was in effect, they would cover the copay for her, providing that Blue Cross was built. She says, Well, they told me the co-pay was excluded and this went on and on and on and I finally said.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] Um, I said I'll tell you what, I talked to an agent. I didn't, I wasn't rude to her, and I said, and I got a reference number, and what I understand is she has Blue Cross Blue Shield, a $3500 deductible plan pay 70% after that. And but American Public Life will help her meet that $3500 deductible and will cover her co-pay instead of her meeting that $3500.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] So anyhow I thought did I just misunderstand somebody or is she, I, I finally told her I said, you know what? and she said, well I need to know exactly what my co-pay is gonna be when I come in. I said, I cannot, I cannot tell you what the provider is gonna charge. It's a 15 minute appointment. It's one thing, a 30 minute appointment, it's gonna be something else. I'm like, but I just wanted to re-verify.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well, and to be fair, that was something I learned going into this. I used to think it was the doctors themselves, the provider's office, but it is very different with each um carrier depending on who she has for coverage and what it is. Now I will say if this alleviates any sort of confusion, um.
[AGENT][NEUTRAL] For this policy, office visits are not covered, so treatment received in office is, but if it was just like say a consultation or something like that, that's not going to be covered under this policy, so I don't know if that's maybe where the confusion came from.
[CUSTOMER][NEUTRAL] OK, that's what was talking yeah, yes, yes, yes, yes, that's what, yeah, so she's coming in, she's coming in for an ultrasound, so that's an office procedure, but then she would, but that would probably be covered but then when she comes back for the follow up after that.
[AGENT][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, so, mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Then that's just a routine office visit and so that she would, she would pay her whatever per uh she would pay the office fee until she hits that deductible. OK, that makes total sense.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes, ma'am. Right.
[AGENT][POSITIVE] That's correct, yes ma'am.
[CUSTOMER][POSITIVE] That makes total sense. OK, OK, and your nam[PII] was.
[AGENT][POSITIVE] You know, and if there's, if there's any like if there's a time if she calls you back if there's this whole he said she said you can do more than welcome to do like a three way call or while she's in the office if she wants verification while you know speaking all of us at the same time you know so that we're all on the same page if that would help I mean that you're more than welcome to do that.
[CUSTOMER][NEUTRAL] Well, I told her that she probably, she might need to call you all back, um, but that was where the confusion is that it covers, I guess maybe procedures and surgeries but not in uh.
[AGENT][NEUTRAL] Treatment received in office, right, but the visits themselves, right.
[CUSTOMER][NEUTRAL] OK, including
[CUSTOMER][NEUTRAL] Including an ultrasound, um.
[AGENT][NEUTRAL] Correct, treatment received in office is covered, the visits are not.
[CUSTOMER][POSITIVE] OK, that makes total sense. Well, that's still a good deal that's still a good deal so right that.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] I, yeah, this insurance is really cool.
[CUSTOMER][NEUTRAL] Yes, it looks like she's having abnormal uterine bleeding and so the provider is going to do an ultrasound to try to get to the bottom of what's wrong with her. And I did tell her that our providers here, if they do a procedure, they do not also charge an office visit. They charge for the procedure only.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] If they're, if, if they are an established patient, now if they walk in and the proprietor's never seen them before, then he's gonna have to establish or take her history, yada yada yada, but she's an, she's a, she is an established patient, so, OK, that, that answers the question.
[AGENT][NEUTRAL] Sure. Consultation, yes.
[AGENT][NEUTRAL] Right, OK, and of course I will leave um a very detailed note on her account uh regarding this um because I do believe that must be the source of the confusion so if and when she calls back, um, you know, of course she doesn't get me whoever else she gets um they'll be able to reference that.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Right, OK, I appreciate that explains 100% why she kept on going on and on about the deduct the co-pay, so.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, well, you know what, even when, even though you pay for health insurance, it still isn't just totally covered for you, you know, none of them are you.
[AGENT][NEGATIVE] Absolutely not, yes.
[CUSTOMER][NEGATIVE] I gotta pay for something, you know, even I.
[AGENT][NEUTRAL] Those deductibles are can be killers, but
[CUSTOMER][NEUTRAL] Yeah, well, and you know a lot of times though you they, they elect the policy that they wanna take out and then they're not, you know, they, they take out the cheapest plan.
[AGENT][POSITIVE] Exactly, yes, absolutely.
[AGENT][POSITIVE] Yes, and that's, yeah, exactly.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Pay for it one way or another.
[CUSTOMER][POSITIVE] You sure do. Well, [PII], you have been a tremendous help. Now I, I can see clearly now.
[AGENT][POSITIVE] Oh I'm happy we were able to, yes, I'm, I'm really glad we were able to identify and pinpoint where that confusion was.
[CUSTOMER][POSITIVE] And I'm gonna put a note in her up there and let her know that put a note that the office routine office visits are not covered only procedures. OK, all right well thank you so much.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] You are very welcome. Did you have any other questions for me, [PII]?
[CUSTOMER][NEUTRAL] No, not at this time. I sure don't. I appreciate your help. OK.
[AGENT][POSITIVE] Alright absolutely thanks for giving us a call have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.