Obtaining reimubursement for services is a complicated process dominated by policy language and code systems.
Resolving Financial Grievances/Disputes
Clients often encounter unexpected charges and coverage denials. Deciding whether to fight or forgo the battle (or negotiate a compromise) can be a major source of anxiety in itself.
What is the source of coverage? There are different rules for challenging decisions from HMOs, PPOs, Medi-Cal, Medicare, CalPERS, Healthy Families, HSAs or an individual plan. It is important to follow the plan's internal appeal/grievance procedure from the beginning. If the situation is urgent, the patient or patient's representative should inquire about the "expedited" procedure. Balance billing is illegal in California. (Health & Safety Code § 1379) This issue arises when a health-care provider sends bills for additional money (the "balance") after the patient's health care plan has already paid the provider what the provider is owed according to the plan and after the patient has made their co-payment.
If a coverage dispute cannot be resolved by internal procedures, HMO/PPO patients may seek independent medical review (IMR), which involves external review of medical records by doctors who are not part of the health plan. If the IMR is decided in the patient's favor, the health care plan must provide the treatment that the patient requested. The IMR process is most often used by patients needing expensive cancer care, metabolic care (especially for obesity), orthopedic care, and neurological disorders.
Medicare beneficiaries are not eligible for the IMR program. Lumetra (800) 841-1602 is the agency that helps Medicare patients deal with greivances and appeals.
California law requires attorneys to "...maintain inviolate the confidence, and at every peril to himself or herself to preserve the secrets, of his or her client." B&P Code § 6068(e)(1)
This web site, started January 2007, is a work in progress. It deals with issues often encountered in my practice and, hopefully, it may answer some of your questions. I will do my best to keep it updated and relevant. Questions related to content, sent by email, are sincerely appreciated and will be answered.
