Insurance Company Complaints

Evaluation

At SBCMS, we support the patient's right to access crucial healthcare services. This guide will walk you through how to file a complaint against your insurance company if you believe that your healthcare rights have been wrongly denied.

Overview

How to Fight Your Insurance Company When Coverage is Denied. Should you have to battle your health insurance company over a denial of coverage, there are steps you can take to avoid health insurance denials before they occur. And if that does not work, there are steps you can take to fight them once they do. The key is organization--having all your paperwork in order, taking detailed notes of your interactions with everyone in the process and understanding your coverage.

Knowledge is Power

Information is power, and this is never truer than when battling a healthcare system. The winner may be the side with the better-organized, more-detailed information. The best bet when dealing with insurers is to minimize the risk of denial, and then if one does come your way, to solve the problem in the early stages.

  • Understand your health insurance policy thoroughly. If you have questions or do not understand any aspect of your coverage, call your insurance company and make them explain it in layman’s terms. Make sure you understand the exclusions and limitations of the policy, and the section on how to appeal.
  • When receiving medical care, make sure your healthcare provider understands what is covered. Doctors deal with many patients and many insurance companies. Do not assume they will remember the particulars of your situation.
  • Take your policy provisions seriously. If it dictates that prior authorization is required, then do not receive care without obtaining that authorization. Assuming that the company will cover you and you can obtain coverage later, even if that is what your doctor tells you, could lead you into a world of bureaucratic nightmares, and might lead to a denial of coverage.

Avoid Denials of Care: Maintain Complete Records and Documentation

You are your own best advocate. You know best what ails you and what questions and concerns you have about your treatment. Take yourself seriously--be your own advocate at all times. Here are some steps to help avoid denials of care and coverage by your health care provider before they occur:

  • Maintain an ongoing medication log documenting all medications and treatments you are currently using.
  • Always try to bring another person to your doctor appointments. He or she can listen and take notes to help you remember what the doctor tells you. Even your own list of questions can fail you if you do not feel well or the questions are not addressed in the order you've written them in.
  • Create a file folder to keep all documents, logs, test results and medication lists so that all your pertinent health information is in one place. Save copies of all paperwork from your doctor and your insurance company. Keep these records in chronological order for easy location.
  • Maintain a detailed log of all health care services and communications (phone, in person, mail, etc.) that you have with your physicians, health insurance company, and any other person spoken to. This cannot be overstated. This log will greatly benefit you should you ever encounter access issues for medications, treatments or procedures.
  • If using an out-of-network provider, establish before care is provided that they will accept your health insurer's payment in full.
  • If there is a claim for which your insurance company will reimburse you only after you've paid your provider out of pocket, be sure to file the claim immediately.
  • If there is a delay in payment, call your insurance company immediately.

If Care is Denied

Assuming you have taken all the above mentioned steps and are still denied coverage, do the following:

  • Review all the paperwork regarding the case immediately, making sure you understand every aspect. Then, with your paperwork in front of you, call your insurance company.
  • The insurance company representative should be able to tell you why you were denied coverage. Make sure you take detailed notes of the conversation.
  • Denial of coverage is often a result of administrative error. If this is the case, you may be able to resolve it on the first call, or with just some minor communication thereafter.
  • Assuming the problem continues, request an itemized bill from the doctor or hospital, and analyze every charge. There are often charges on these bills for services not delivered. If you find any, notify the doctor or hospital immediately to get the bill adjusted. Then, notify your insurer.
  • Often, however, the denial has been legitimately issued. The insurance company may not consider your medical procedure necessary, may consider it experimental or outside their coverage evidence based guidelines. That being the case, it is now time to take additional steps.
  • Request a formal review by the insurance company. The customer service representative can tell you the specific procedures required. Then, state your case for appeal in writing, and send the letter via certified mail with return receipt requested. Make sure to do this immediately. Some companies have time limits on when appeal requests can be filed.

California Health Plan Complaint Process

Who Regulates What Type of Health Plan?

The majority of California’s health plans are regulated by either the California Department of Insurance (CDI) or the California Department of Managed Health Care (DMHC). The CDI regulates point-of-service health plans and certain Preferred Provider Organization (PPO) health plans underwritten by health insurance companies authorized by the CDI.

The CDI does not regulate Health Maintenance Organizations (HMOs) or certain PPOs, which fall under the Knox-Keene Act (i.e. Blue Cross of California or Blue Shield of California).

For a list of health insurance companies regulated by the Department of Insurance, visit their website at www.insurance.ca.gov.  For a list of the HMOs and other healthcare service plans regulated by the Department of Managed Health Care, please visit the DMHC website at www.dmhc.ca.gov

  • View all the paperwork regarding the case
  • Understand your health insurance policy thoroughly.