Protections for You and Your Choice

  Why TMA Cares About Your Choice   Knowing the Differences    Sample Complaint Form   Healthplan Checklist

 

When an insurer or health plan refuses to pay for medical treatment, patients and their families must carry the burden of paying for the doctors, laboratory tests, and hospitals. But the risks are higher, and the consequences more immediate and severe, when the delays or denial of payment, preauthorization of treatment, referral to specialists, and hospitalization undermines medically necessary care.

In 1997, the Texas Legislature made Texas the first state to require a system of independent review of insurer decisions by reviewers who do not work for the insurance company or HMO. Use of the Independent Review Organization (IRO) process usually is permitted only after patients have completed the insurer's internal appeals process.

In Texas, insurance companies and health maintenance organizations (HMOs) are regulated  by the Texas Department of Insurance (TDI). The department, headed by an insurance commissioner appointed by the governor, is charged with making sure insurance companies have adequate financial resources to cover claims and that patients are treated fairly by their insurers.

Appeals and Complaints

A good start in consumer protection comes when you make sure that you and your physician provide accurate and timely information to the insurer in order to obtain preauthorization or to make sure your claim is processed promptly. Read your plan's handbook before you receive treatment to make sure your treatment is covered. Check the information on claims forms for accuracy, or ask your physician to do so. And keep a record of everyone you talk to at the insurance company, including the date, time, and representative's name. A summary of what patients can do to avoid denials and to appeal insurer decisions is available at insure.com. The link includes sample letters for all levels of insurer appeals.

1.  Complaining to the Insurer

Many complaints about coverage and payment of claims can be handled with a telephone call to the insurer's customer service number, which is usually listed on your insurance card. Sometimes, however, a problem cannot be resolved and you must use the insurer's grievance process.

The first step is to write a letter to your HMO or insurance company describing the problem and giving as many facts as you can. Names, dates and places will help the insurer understand where the problem lies, but don't forget to tell the insurer exactly what you want it to do to solve the problem. Make your description as short and clear as possible, and don't exaggerate. Include copies of all papers relating to the problem, such as benefit statements, denial letters, and checks.

Most important, mail the letter to the correct address to avoid delays. The customer service address may be listed on your insurance card, but you may want to call the insurer first to make sure the address hasn't changed. Also consider sending the letter by registered or return-receipt mail to confirm the delivery.

Sample letter of a complaint to a health plan.

The second step  is to complete your health plan's complaint process. Each insurer has its own process for dealing with complaints. Your plan may respond to your letter by asking you to fill out a form, provide additional information, or speak to a plan representative. Keep copies of all written communications. If you speak to someone, in person or on the phone, note the date, what was said, and who said it.

  2.  Independent Review

When a health insurer refuses to pay for treatments that it considers to be medically unnecessary or inappropriate, you may be able to have an IRO review the decision. The IRO review is paid for by the insurer, and the insurance company or HMO must comply with the decision.

IRO reviews are available for insurers that are required by law to participate or that volunteer to participate. Call your insurer to find out whether the company or HMO uses the IRO process.

Independent review is not available when an insurer refuses to pay for a service that is not covered by the insurance, or when you receive coverage through Medicare, Medicaid, or a Medicare HMO. You are not permitted to appeal to an IRO when an insurer determines -- after the treatment -- that the care was either not appropriate or medically necessary.

When a patient is faced with a life-threatening condition, you can bypass the insurer's internal appeals process with an immediate appeal through an IRO. Otherwise, patients must complete the insurer's appeals process before beginning independent review.

 

If your insurer denies treatment as inappropriate or unnecessary, it should provide you with the denial in writing. It also should give you forms requesting an in-company appeal and an IRO review. The forms are returned to the health plan.

The Texas Department of Insurance maintains an IRO Information Line at (888) 834-2476.

  • For further information about the IRO appeals process, see the Texas Department of Insurance's webpage on the IRO process.

  Complaining to Insurance Regulators

1.  Insurance Companies and HMOs

If your insurer does not participate in the IRO process, or if you are unhappy with decisions in areas that aren't covered by independent review, you may want to consider filing a complaint with TDI or one of the state and federal agencies that oversees other types of insurers.

 

TDI investigates complaints against insurance companies, HMOs, insurance agents, adjusters, and "fully insured" or "fully funded health benefit plans." The last two are health insurance plans that an employer purchases from an insurance company or HMO. TDI will investigate claims disputes and disagreements over benefits, false advertising and misrepresentation, and suspected insurance fraud.

TDI maintains an online complaint form  that can be printed for your records once it is complete.

Once TDI receives your letter and contacts the insurer, you may receive a letter from TDI saying the dispute is resolved. Sometimes that letter is mistakenly sent before the dispute is resolved, so do not hesitate to contact TDI to follow up.

2.  Self-Funded Plans

Many employers have self-funded health benefit plans, for which funds are set aside to pay health care claims for employees and their families. Insurance companies, HMOs, or an administrator may handle the claims paperwork. Federal law, not state law, applies to these self-funded plans, and complaints must be filed with the U.S. Department of Labor.

Group health plans maintained by some government agencies, churches, and out-of-state Blue Cross organizations also are exempt from most Texas insurance regulations.

If you have a self-funded plan offered by an employer or union, take complaints and appeals to the person or office listed in your benefits booklet who is to handle problems and appeals. If the complaint remains unresolved, call the Dallas office of the U.S. Department of Labor's Pension and Welfare Benefits Administration at (214) 767-6831.

If the plan is self-funded but offered through a government or church employer, responsibility for resolving disputes rests with the governing body of the employer sponsoring the plan, such as a school board, commissioners court, or church board.

3.  Workers' Compensation

If your dispute involves workers' compensation benefits , call the Texas Division of Workers' Compensation at (800) 252-7031 or (512) 933-1899 in Austin. For complaints about workers' compensation insurers, visit the Complaints section of the TDI website.  

4.  Medicare/Medicaid

Medicare patients are entitled to special grievance and appeal rights. Your health plan is required to give you a complete written explanation of your rights. Medicare also maintains a website which is very helpful.

Medicare and Medicaid members also can call the Centers for Medicare and Medicaid Services (CMS) regional office in Dallas to make a complaint. The telephone number is (214) 767-6401.

  Will Your Plan Still Be Around When You Need It?

Whether your health insurer or HMO has enough money to pay its expected claims is a key concern for TDI regulators. You can see how your insurer is doing financially by checking company profiles and financial information at the following webpages:


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