Health Insurance Billing Issues

by Michael Grodsky on 2015-10-02

Lisa Zamosky’s excellent L.A. Times article on 09/18/2015 was about people being illegally billed for charges not paid by Medi-Cal.  Below are some contacts that may be of assistance in resolving billing and other healthcare issues for not just Medi-Cal.

Medi-Cal

  • If you get a bill, contact your doctor’s office to confirm they have all of your insurance information. Billing Medi-Cal patients for any balance not covered by insurance is a violation of the law.
  • Don’t ignore bills. Providers regularly send outstanding bills to collections, which can wreak havoc on your credit. Don’t ignore notices.
  • The Medi-Cal Ombudsman can help members with billing matters. Call (888) 452-8609 or send email to MMCDOmbudsmanOffice@dhcs.ca.gov

Health Plan Issues

  • The California Department of Managed Health Care Help Center offers assistance at (888) 466-2219 or online at www.HealthHelp.ca.gov.
  • Neighborhood Legal Services of Los Angeles County’s Health Consumer Center provides L.A. County residents with free advice and legal services. Attorneys can be reached at (800) 896-3202.
  • Outside of L.A. County, call the Health Consumer Alliance statewide line at (888) 804-3536 or visit Healthconsumer.org.

Patient advocate and medical bill specialist services

  • Many large and mid-size companies offer medical advocate services. Check with your human resources department.
  • Claims Assistance Professionals: http://www.claims.org/refer.php
  • Alliance of Professional Health Advocates directory: http://www.advoconnection.com/
  • Medical Billing Advocates of America: http://billadvocates.com/dispute-medical-bill/
  • Health Proponent offers “access to expert, personalized help to resolve a full range of healthcare and insurance-related problems, and can save you time, money and worry.” If they are able to negotiate a lower bill from your healthcare provider, for example, they take 25% of the savings for their fee. You must enroll in their basic program for $59.95/mo (as of this writing) in order to use their bill saver program. For details send an email to info@haihealthproponent.com or call 1-866-939-3435.

How to File a Complaint, Grievance, Appeal, or Request for Independent Medical Review.

If you do not agree with a coverage decision by your insurance plan, the first step is to file a grievance/appeal with your health plan by phone, mail, fax. You may also be able to file on your plan’s website. If you don’t get traction with your appeal, review your next steps in the letter the insurance company sent, which is to file your next appeal/complaint with California Department of Managed Health Care (regulates most HMO plans), or California Department of Insurance (regulates most PPO plans).

Health plans are required by law to have a grievance process in place to resolve member complaints within 30 days. In most circumstances, you are required to file a grievance regarding each issue/request with your health plan and participate in the process for 30 days before submitting a complaint to the Department. Exceptions to this requirement include when there is an immediate threat to your health or the request was denied as experimental/investigational in either instance, you may seek DMHC’s help immediately.

California Department of Managed Health Care (DMHC)
The DMHC regulates most HMO plans

  • Phone: 888-466-2219
  • Web: http://www.dmhc.ca.gov/
  • Click “File a Complaint” or call 1-888-466-2219
  • Call if you have an immediate need for health services and a delay could seriously jeopardize your health.
  • Email inquiries: please use the DMHC website Contact Form.

California Department of Insurance (DOI)
The DOI regulates most PPO plans

Covered California

  • If you do not agree with an enrollment decision by Covered CA, call them at 800-300-1506 and ask for an appeal form. It is called Request for a State Fair Hearing to Appeal a Covered CA Eligibility Determination.
  • If you do not agree with a coverage decision made by your insurance plan, do not call Covered CA, but instead file a grievance/appeal with your health plan by phone or by mail. You may also be able to file on your plan’s website.

Medi-Cal

Health plans are required by law to have a grievance process in place to resolve member complaints within 30 days. In most circumstances, you are required to file a grievance regarding each issue/request with your health plan and participate in the process for 30 days before submitting a complaint to the Department. Exceptions to this requirement include when there is an immediate threat to your health or the request was denied as experimental/investigational in either instance, you may seek DMHC’s help immediately.

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