Author Topic: Complaint with the Dept of Ins?  (Read 1312 times)

Christy

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Complaint with the Dept of Ins?
« on: January 28, 2014, 12:29:42 PM »
Has anyone ever actually filed a complaint with their state’s Dept. of Insurance? I am in NY in case anyone has specific advice about NY.
Although the insurer is in NJ. How would that work across states?

I have a peculiar situation. I submitted a behavioral health claim to a small union insurer using cpt 90791. We got a letter back that this is an invalid code and unprocessable?!?! This code has been valid since Jan 2013. The claim was submitted for a Nov 2013 dos.

I have called multiple times and been told that they cannot process the claim because 90791 is not in their “system.”  I was told that I should resubmit it with a different code. The one rep there is quite unenthusiastic about her job. They have paid the subsequent 90834s that we have billed. I cannot call for claim status as they refuse to enter it into their system! A supervisor is never available to talk. I have faxed the claim over 4 times and requested that a supervisor call me back.

Since this union is part of PHCS/Multiplan and the provider is par with them, I attempted to file a complaint with them, but they were not very helpful and said I needed to pursue this myself.

I am not sure how far I should go with this, as behavioral health is a sensitive specialty regarding patient privacy, etc. I need to check with the provider, but my instincts are to speak to a Union head and/or get the patient involved.

But, just curious, has anyone ever filed a complaint with the Dept. of Ins? How did that go?

All input and comments welcome and appreciated!

Michele

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Re: Complaint with the Dept of Ins?
« Reply #1 on: January 28, 2014, 01:37:45 PM »
I have in NYS.  Actually a couple of times.  If the provider is in NY you file in NY.  It is a fairly easy process.  Complaint is filed online.  Then you sit back and wait.  I have had both favorable and unfavorable responses.  In the case you describe below I believe you should be good. 

http://www.dfs.ny.gov/consumer/fileacomplaint.htm

Good luck!
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Christy

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Re: Complaint with the Dept of Ins?
« Reply #2 on: January 28, 2014, 04:50:37 PM »
thanks so much, Michele!

Billing2

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Re: Complaint with the Dept of Ins?
« Reply #3 on: January 28, 2014, 05:20:26 PM »
I had a problem with one of the Union in New Jersey too .  I called New Jersey insurance and banking because it was a union they told me they could not assist.  They told me I would need to go to the Department of Labor.  The union was for a city in New Jersey so I called the mayor's office and I stated that we had  claims outstanding that their union would not pay for wrong CPT code  never gave any names never gave any PHI. The mayor told me he would contact the person that would need to fix  it and I would be paid within 7 to 10 days if not to tel him know. I got paid in 7 days. I had never done that before.  Since then when I bill that union I never have a problem.

Christy

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Re: Complaint with the Dept of Ins?
« Reply #4 on: January 28, 2014, 07:46:23 PM »
wow, Billing2! good move!

Michele

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Re: Complaint with the Dept of Ins?
« Reply #5 on: January 29, 2014, 08:40:42 AM »
We have used local politicians as well.  It has been helpful for us in the past too!  We do whatever we have to to get our docs paid.
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PMRNC

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Re: Complaint with the Dept of Ins?
« Reply #6 on: January 29, 2014, 12:39:07 PM »
 
Quote
small union insurer

Right there.. forget Dept of Insurance.. this is an ERISA claim. An ERISA claim is never YOUR claim, it's the patient's claim and they have to appeal it with their administrator, employer/union. Bill the patient and let them appeal.

With ERISA, the dept of insurance has NO value or leverage.

Linda Walker
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