Appeals, complaints or grievances with an Insurance Company?

Introduction 

The process of appeals & grievances gets very technical, legal, etc.  I won’t even attempt to summarize it here.  Please follow the links below, guides & summaries to the right,  check your policy – evidence of coverage and check the law.

Medical Procedures?

• Was your procedure Medically  Necessary?
  • Los Angeles Medical Necessity Denials Lawyer
  • Los Angeles Health Insurance Lawyers
• Independent Medical Review  IMR  
  • Is it a coverage mandated under ACA/Obamacare?
• Did you use the Correct MD or hospital – Provider List and
• Did you Review the procedures in your actual policy, evidence of coverage?

Reasons why the Claim might be denied

• Did you tell the truth on your application?
• Nearly 15% of claims submitted to private payers are initially denied
  • Insurers’ denial rates — a critical measure of how reliably they pay for customers’ care — remain mostly secret to the public. Federal and state regulators have done little to change that.
  • Claims Denials and Appeals in ACA Marketplace Plans in 2021   kff.org
  • Wrestling With a Giant: How to Dispute a Hospital Bill
• Here’s where they write to your MD, prior to ACA/Obamcare before a claim is even turned in.
  
• How about doing a pros & cons spreadsheet – Ben Franklin method?  It’s important to know the other sides point of view and potential arguments & evidence. 
  • Plaintiff whose insurer delayed surgery is awarded $14 million over opioid dependency   LA Times
• Billing Codes – Satire or how it really works?
• Was the policy in force?  Lapse non pay?
• Department of Labor on Filing a Health Claim 
• Most U.S. adults don’t know they can fight insurance denials, new study finds  

Insurance Company & Regulatory Agency
Grievance Procedures & Forms

• Check your EOC – Evidence of Coverage for procedures & where to get forms.
• Aetna
• Blue Cross Grievance Procedures
• Notice
• Blue Shield – General Info.  Appeals & Grievances  PO Box 629007  El Dorado Hills , CA 95762 – 9007  Fax: (916) 350 – 7585
• CA Department of Insurance  
• IMR – Independent Medical Review  
• REQUEST FOR REVIEW  Molina Health Care OF CANCELLATION, RECISSION, OR NONRENEWAL OF HEALTH CARE SERVICE PLAN BENEFITS
• hhs.gov/curbing-insurance-cancellations
• DGS Office of Administrative Hearings
• Kaiser Member Grievance Form 

Enforcement

Anthem Blue Cross Fined $415K since the California Department of Managed Health Care said it found 40 cases in which Anthem deprived members of their grievance and appeal rights. –   ^{CA Healthline 5.3.2016}

WOW!!! 2.8 Million June 2019 ^{CA Managed Health Care} * ^{Insure Me Kevin.com  *} 

Dealing with Customer Service Issues

• First and foremost, be polite. These are crazy days as well for service reps, nearly all of whom aren’t to blame for their companies’ penny-pinching practices. A little civility goes a long way.
• Don’t be shy about escalating. Front-line service reps are frequently not given the power to resolve matters on their own and will often give an unsatisfactory response. Ask to speak with a supervisor.
• If that doesn’t work, write to the company’s chief executive or president, detailing the nature of the problem and providing as much documentation as possible. Most big companies have special dispute-resolution departments at senior levels.
• Be persistent. If it becomes clear that you’re not going away, some companies will finally throw in the towel and offer the response you’re seeking. Squeaky wheels and all that. ^{LA Times 8.8.2020} *

From CMS Site

• Regulations & Guidance
• Fact Sheets & FAQs
• Letters & News Releases
• State External Appeals Review Processes

FAQ’s

• I’m having a problem finding a lab that’s approved by my Insurance Company. It’s not clear if the lab in the same medical group IPA where my doctor PCP is. I’m waiting to hear back.
  • What if my illness gets worse?
• One thing we have to be careful of, is not to let your illness get worse. There is a duty to mitigate your damages, not to let your health get worse. Insurance Companies are NOT your parents! IMHO they are not responsible for your health. You have a simple contract to pay them a premium and if you have a claim, they have to pay what the contract – policy says.  IMHO people don’t want to take responsibility. They want someone else to be in charge. Like having the Government take over?
  • injury victims often fail to mitigate their damages is in seeking medical treatment. An injured person should seek reasonable medical treatment for any injuries that he or he has suffered. If a delay in seeking medical treatment exacerbates the injuries and causes further harm, or if delays in seeking treatment lead medical costs to increase, the victim may not be able to recover the additional damages for the added harm.
  • For example, a pedestrian may suffer a broken arm when she is hit by a car. If she delays getting the break set, and it then heals incorrectly, causing her extended pain and the eventual medical bills to increase, she cannot recover for the increase in damages.
  • duty to mitigate requires only that the plaintiff made reasonable efforts and expenditures to resolve, lessen, and otherwise minimize their injuries and the suffering caused by such injuries.
    • You should always take reasonable steps towards resolving your injuries and the suffering caused by your injuries, for three reasons:
      • 1) for your own well-being, you should pursue proper medical care and therapy as soon as possible;
      • 2) you are entitled to damages for any expenditures put towards reasonable mitigation efforts; and
      • 3) if you do take reasonable steps to mitigate, then the defendant will have an excellent defense argument that may ultimately reduce their damages liability and leave you with a much smaller damages award.  ^{Kopp Law} *
    • Jury Instructions Mitigate Damages 
  • Check out our tools to find providers for most Insurance Companies in CA
    .
    .

• I recently had an appt appointment  to establish care with a #primary physician after 3 yrs without. Various tests were done to assess my current health.
  • I was surprised that all were not covered as part of a well woman visit or as preventative screenings.
  • A test for Hep C antibodies was covered but the Hep C detection test was not.
  • Blood test for lipids and triglycerides was covered but not for other blood chemicals.
  • I would suspect both were necessary to provide a health profile.
  • The Dr. noticed a bulge of sorts by my naval so she ordered an Abdominal Aortic Aneurysm ultrasound which was not covered.
  • The AAA test is covered under the Affordable Care Act and I met four of the risk factors for checking so why was that not considered preventative screening.
  • I have filed a grievance but wonder if there’s more info I need to submit from the Doctor as to why the various tests were done.
• We are talking about what ACA defines as preventative care. Not “establishing” care or “assessing current” health.
  • Here’s what is listed as preventative care:
    • healthcare.gov
    • Blue Shield’s List
    • Our Webpage on Preventative Care
  • Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92
  • If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible.
    • Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016
  • Medical Necessity
  • Clinical Guidelines Blue Shield .
    .
    .
• My Medicare Advantage plan, with United Health Care denied coverage for a home health care nurse who came to our house two or three days a week for almost four months.
  • I was being treated by Wound Care at Mission Hospital in Asheville, NC. Because I live 75 miles away from them, the doctors authorized a home health nurse and had me come in one day each week and later every other week.
  • It was a great service since my husband is 88 and cannot drive the 150 mile round trip and my injury was to my right ankle so I was not supposed to be driving long distances.
  • I have read that Medicare Advantage plans often deny this coverage although Medicare provides it.
  • Any advice for appealing this???
• Well let’s research the issue first:
  • Surgical dressing services
  • Medicare Part B (Medical Insurance) covers medically necessary treatment of a surgical or surgically treated wound.
  • Your costs in Original Medicare
    • You pay 20% of the Medicare-approved amount for your doctor’s or other health care provider’s services. You pay a fixed Copayment for these services when you get them in a hospital outpatient setting. The Part B deductible applies. You pay nothing for the supplies. https://www.medicare.gov/coverage/surgical-dressing-services
  • UHC Bulletin on Wound Care This bulletin is beyond our paygrade… Try the links above.
  • Home health aide services: Medicare will pay for part-time or intermittent home health aide services (like personal care), if needed to maintain your health or treat your illness or injury. Medicare doesn’t cover home health aide services unless you’re also getting
  • skilled care. Skilled care includes:
    • ■ Skilled nursing care
    • ■ Physical therapy
    • ■ Speech-language pathology services
    • ■ Continuing occupational therapy, if you no longer need any of the above
  • Medicare & Home Health Care # 10969
  • Medicare Benefit Policy Manual
  • Medstarvna.org Wound Care at Home
  • Medically Necessary – means health care services, supplies, or drugs needed for the prevention, diagnosis, or treatment of your sickness, injury or illness that are all of the following as determined by us or our designee, within our sole discretion:
  • • In accordance with Generally Accepted Standards of Medical Practice.
  • • Most appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, or illness.
  • • Not mainly for your convenience or that of your doctor or other health care provider.
  • • Meet, but do not exceed your medical need, are at least as beneficial as an existing and
  • available medically appropriate alternative, and are furnished in the most cost-effective manner that may be provided safely and effectively.
  • Home Health Aide – A home health aide provides services that don’t need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.
  • Home Health Care – Skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Benefits Chart in Chapter 4, Section 2.1 under the heading “Home health agency care.” If you need home health care services, our plan will cover these services for you provided the Medicare coverage requirements are met. Home health care can include services from a home health aide if the services are part of the home health plan of care for your illness or injury. They aren’t covered unless you are also getting a covered skilled service. Home health services don’t include the services of housekeepers, food service arrangements, or full-time nursing care at home.
  • Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Our webpage on Medical Necessity
  • Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare health plans, including our plan, must cover all of the services that are covered by Medicare Part A and B.
  • Prior Authorization – Approval in advance to get covered services or certain drugs that may or may not be on our drug list (formulary). Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4. Covered drugs that need prior authorization are marked in the formulary.
  • Send me copies of your actual bills and the denials… It doesn’t look hopeful at this time. Did you follow the appeals procedure for UHC?
    .
    .
• I have a dental claim that was denied as the Insurance Company says I didn’t have 12 months of coverage as mandated in the policy.

  • A 12-month waiting period applies to all Major Services Page 1 of EOC

    My first appeal was denied as the Appeals Review said:

    You have requested that xxx Insurance Company waves the waiting period and reprocess the claims referenced below to allow benefit coverage. We are unable to approve your request.

    During the research of your concerns it was determined that the waiting period has not been satisfied. As stated in your plan’s Evidence of Coverage (EOC) there is a 12-month waiting period before xxx Insurance will pay for major services.

    I want to file another appeal, as the Insurance Company should have it in their records that I’ve had continuous coverage since 2014. The appeals court should find in my favor as the Insurance Company should just pay me, as their records should show that!

• I don’t think so. The Insurance Company has clearly stated in unequivocal terms that you had a lapse in coverage from 9.30.2019 to 8.1.2020!
  • Sure, their records are wrong as you have cancelled checks and I have my commission statements. If you’re going to take this to Appeals, Complaints with Department of Managed Health Care or Small Claims Court, the burden of proof is on you.
  • Please review the Appeals Guides above.
  • Here’s some excerpts:
    • It is important to remember that you do have rights which are described in your insurance policy handbook.
    • A health insurance policy is a contract between you, the policy holder, and the insurance company. A denial is a “contract dispute,” and your appeal must be based both on the reason for the denial and provisions in your insurance policy, contract
    • Your health insurance plan must notify you in writing of the reason they did not authorize a specific request or denied payment of a service as well as how to appeal their decision
    • One of the most important elements of your appeal packet is a clear, concise letter that addresses very specifically the reason of the denial, and incorporates the terms of your policy (or plan language). Patient Advocate.org
  • Gathering the Documents You Need
    • Prepare for the hearing by gathering any evidence that will help the judge understand the case. Your evidence may include any written contract, receipt, letters, written estimates, repair orders, photographs, canceled checks, account books, advertisements, warranties, service contracts, or other documents. Like your Insurance Brokers Commission Statements. Small Claims Guide
    • Please also review these other pages on our website:
      • Read the policy, denial letters and other correspondence like where the Insurance Company said that your coverage was lapsed three times and then when you think you understand it, read it again.
      • Our webpage on the important of reading the EOC Evidence of Coverage
      • Court case stating a policyholder must read their policy.
      • Insurance Companies give the wrong answer and then tell the Department of Insurance that an application was never sent in, when they told the agent it would be denied and not sent in
      • I’m not practising law or giving legal advice. I’m just showing you research.
      • We are not interested in what someone is alleged to have told someone else over the phone
      • Don’t get caught off guard at the appeals hearing or small claims court, make sure you have the evidence that the Insurance Company will show to defend their denial of your claim
• Nah, Steve,
  • You’re wrong. I didn’t have to do all the work you said. Blue Shield is paying my claim!
  • we have approved your request for payment of claims on September 7, 2020 and September 14, 2020, for $737.00 per claim
  • >
• Sorry, no.
  • Please read the entire letter:

It is important to understand that this decision has been made on an exception basis and, in making this decision, Blue Shield does not waive any of its rights to enforce the provisions of the enrollee’s health plan. Your dental plan requires that you have continuous coverage for 12 months prior to any major dental services are covered. You had two months of coverage from August 1, 2020 through September 30, 2020

• Let’s be clear what exception means:
  • The definition of an exception is something that is outside of the rules or outside of the normal expectations.
  • An example of an exception is when you are normally supposed to be home by midnight but your parents let you stay out until 1 AM, just for one night.  
  • There will be no exceptions to this rule.  
  • I ask that you grant an exception in this case
  • I understand my current policy is not obligated to pay for this, but I would like to request an exception.
• Health Insurance Appeals and Exception Guide  
• Thus, if you have any more claims for major work, it WILL NOT be paid!