The Therapist
(January/February 2009)

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CAMFT receives many calls a month from members frustrated by issues of patient care and health plan or insurance coverage policies. Has your patient been denied services? Has your claim been denied for lack of medical necessity? Has your client been denied continued sessions?

Both the Department of Insurance (“DOI”) and the Department of Managed Health Care (“DMHC”) have the roll of protecting the consumer and making sure the law is not being broken by the health plans or insurers. However, the DOI and DMHC cannot act upon violations of the law if they are not aware of the violations.

Both the Department of Insurance (“DOI”) and the Department of Managed Health Care (“DMHC”) have Consumer Hotline numbers to assist consumers with their rights as a patient against health plans and insurers. As their therapist, you can help your patient notify the DMHC and DOI of unfair practices, wrongful denials, and general violations of the law. Of course we recommend you advise your clients to make their own complaint, but you too, as their provider can alert the DOI and DMHC to the existing problems. Here are Consumer Hotline numbers:

DMHC
1-888-HMO-2219 (1-888-466-2219)

DOI
1-800-927-HELP (4357)

When you do call the DMHC or DOI to report an insurer or plan, make sure to indicate that you “are calling on behalf of your client, the enrollee.” Because this is a hotline specifically available to consumers, you will need to advise the department of this representation on your part.

Some providers have indicated hesitation in “whistle blowing” on an insurer or health plan in fear of retaliation. Although by law an insurer or health plan cannot retaliate against a provider for such action, your concern is understandable and occasionally valid. It is CAMFT’s recommendation that you indicate to the DOI or DMHC if you have those concerns.

Are you unsure whether to call the DOI or DMHC? The DMHC oversees most health care service plans (including Kaiser Permanente), health maintenance organizations (“HMOs”), as well as Blue Cross and Blue Shield participating provider organizations (“PPOs.”) The DOI oversees most other insurance companies and their PPOs in California. If you are still confused as to which department to reach, simply start with one and give them the insurer’s or health plan’s name and they will direct you to the right department.

To learn more about both the DOI and DMHC consumer grievance process the following two websites can provide additional information: http://www.hmohelp.ca.gov/ http://www.insurance.ca.gov/

It is through your help, and your reporting of violations, that the departments can act on these unfair practices and assure insurer and health plan compliance.

Note: The Consumer Hotline numbers are for violations of consumer rights. If your complaint against a health plan or insurer revolves around provider reimbursement or unfair contract negotiation tactics, please visit the above websites and follow the following steps:

DMHC

• Click on Health Care Providers tab
• Click on Consumer tab
• Follow complaint instructions

DOI

• Click on Consumer tab
• Click on Consumer and Health Care Provider Complaints tab
• Click on Health Care Provider Complaints tab
• Follow File a Complaint instructions

 

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Catherine L. Atkins, JD, is a Staff Attorney at CAMFT. Cathy is available to answer members’ questions regarding business, legal, and ethical issues.

 

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This article appeared in the January/February 2009 issue of The Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. The information contained in this article is intended to provide guidelines for addressing legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such information as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained herein.