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Resolving Medical Claim Denials with State Insurance Regulators


When patients are wrongfully denied a claim and your medical practice has done all it can, there is one more place to turn: your state's insurance department.

I have found insurance companies' Achilles ' heel; the Kryptonite that can wreak havoc on them; the one thing that makes them shudder in fear. Yes, it is your state's department of insurance. I've briefly mentioned them in past blogs, but over the past two months there seems to be an influx of situations where I am steering patients to their state's office.

The main function of the department of insurance is to be the advocate for the patient fighting a wrong-doing by their insurance company. They are in place to be a watchdog of sorts to make sure insurance companies are not taking advantage of their customers: your patients. There is only so much you can do for a patient when their insurance company denies a claim, terminates their plan, increases their premiums or copays without informing them, etc.

I've had personal experience several years ago with Blue Cross denying claims where I had authorization, but they continued to deny them for two years. Yes, I fought for two years to get these claims paid. Bless my physicians and the hospital for not sending me to collections as they were copied via e-mail on all correspondence to Blue Cross regarding my claims. I think they were surprised by my perseverance.

Regardless, after two year of absolute frustration, I took copies of all of my documentation including the continued denials and nasty letters from Blue Cross and mailed it all up to the California Department of Insurance. For two weeks, the mailbox was empty. On day 15 after sending my very large envelope up to them, I received a notification that my claim with them had been closed and I would hear from Blue Cross shortly. Well, I didn't know what that meant, until the next day. All claims were paid according to the fee schedule the physicians had with Blue Cross. Everything. I was so happy, relieved, and overwhelmed. I had no idea that entity existed, and I could have used them so much earlier! Bottom line: The California Department of Insurance found Blue Cross had denied my claims unnecessarily and held them accountable to the agreement that I had with the payer.

As I mentioned, over the past two months, I have turned several patients to their state's department of insurance for claims denial of "not medically necessary," early termination of plan, and increase in copays without prior written documentation. This is something that the patient has to do themselves. Most insurance department websites have a link to download and fill out a form outlining the complaint. Any documentation that you can provide the patient showing medical necessity (i.e., chart notes, prescriptions, labs, films, etc.) is how you can help them. They need to arm themselves with everything they have including the denial of the Explanation of Benefits from the insurance company. Mail all of that to the insurance department after taking a copy of it for their records. If they find the insurance company at fault, you should be paid within a few weeks.

What concerns me is the recent influx of these types of situations where the patient is being denied unnecessarily. Who is making this decision at the insurance company? Surely they cannot know better than you what your patients need. Is this a sign of what is to come with the new healthcare laws? Is this the way the insurance companies are going to make their profits, at the expense of your patients? It is so very wrong. 

Arm your patients with this nugget of knowledge and watch those insurance companies shrivel in despair!

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