There may be instances when you have a dispute with your health insurance company. For example, the insurance company may deny a claim that you believe should be covered, or you have difficulty getting approval for certain counseling services rendered. In such cases, you have the right to make a complaint.
Insurance is regulated by the states: Insurance is regulated by the states. This system of regulation stems from the McCarran-Ferguson Act of 1945, which describes state regulation and taxation of the industry as being in “the public interest” and clearly gives it preeminence over federal law. Each state has its own set of statutes and rules.
Here are the steps to take if you need to make a complaint about your health insurance in your state:
Step 1: Review Your Insurance Policy
Before filing a complaint, ensure you have a clear understanding of your client’s policy terms and conditions. You may find that the issue at hand is addressed in their policy documents. If you don't have a copy of the insurance policy, request one from the insurance company.
Step 2: Contact Your Insurance Company
The first step is usually to bring the issue to the insurance company's attention. You can do this by calling their customer service number or writing a letter. Make sure to keep a record of all communications and document the dates, times, and the content of your conversations.
Step 3: File a Formal Complaint with the Insurance Company
If the issue is not resolved after initial contact, you may need to file a formal complaint with the insurance company. This process may vary depending on the company. Some insurance companies may have an online form or a specific process for filing complaints. Make sure to include all relevant information, including policy number, claim number (if applicable), CPT Code, and a detailed description of your issue.
Step 4: Contact Your State's Department of Insurance
If your issue is still not resolved after following the insurance company's formal complaint process, you can escalate the matter to your state's Department of Insurance (DOI). The DOI regulates insurance companies and can help resolve disputes between consumers and insurers. You can find the contact information for your state's DOI online.
Though contacting the DOI is step 4, ACA recommends making the complaint to coincide with step 3 in the most extreme cases. You can find this information by checking your states government web page.
Step 5: File a Complaint with Your State's Department of Insurance
Every state DOI has a process for filing insurance-related complaints. This typically involves filling out a complaint form and providing supporting documentation. The complaint form will ask for details about your issue and what steps you have taken to resolve it. Be as detailed as possible and include copies of any communication or documentation relevant to your complaint.
Step 6: Await Investigation and Response
Once your complaint is filed, the DOI will review it and may investigate further. They may contact the insurance company for their side of the story. It may take some time for the DOI to complete their investigation, but they generally will respond with their findings.
Practice Patience When Filing a Complaint
While dealing with insurance disputes can be frustrating, remember that you have rights as a provider, and your client has rights as the policy holder. If you feel the health insurance company has treated you or your client unfairly, don't hesitate to file a complaint. Keep detailed records and be persistent. It's important to stand up for your rights and ensure you're receiving the coverage you're entitled to under your policy.
Also remember to engage with your state Counseling Branch, and Licensure Board for guidance.
Note: This document provides general steps and may not apply to all situations. It's always good to consult with a legal professional or a consumer advocate when dealing with complex insurance issues. Your state’s attorney office may be a resource to you when dealing with insurance concerns.