Wiki Filing Complaint with state insurance board

[dogwhisperer36]

Hi There,

Has anyone filed a complaint against an insurance company with your state insurance board? Did it help, or did it make things worse? Without naming any names, this is our situation.

We are having problems with one particular insurance company who is refusing to process our claims as an out of network provider. We have prior authorization to bill as an out of network provider. We are totally prepared for this particular insurance company to pay the patient directly since we are out of network. Unfortunately, they are refusing to even process our claims. They say that once we are enrolled, we should rebill. Customer service is less than helpful, and the provider rep is even less helpful, so our thoughts are to either file a complaint with our state, or charge the patient directly and let them try to get their insurance to pay.

Any insight you can provide would be helpful.

Thank you,

Tara

 

[thomas7331]

I have only limited experience in this area, but I offer a couple of thoughts. First of all, I'd point out that the state insurance commissioner has limited authority to help you so unless you are sure that the insurance company has violated a state statute, there is likely not much they will be able to do. For starters, states can only regulate fully-insured commercial plans operating within their jurisdictions. Many patients' employer-sponsored plans (especially insurance carried by large multi-state companies) are self-insured and are not within the jurisdiction of state insurance regulators. Second of all, it's been my experience that state insurance commissioners are more focused on regulating the types of plans that are offered for sale to state residents than they are concerned about insurance company relationships with providers about claims payment. One physician I worked with told me that when a large group of physicians met with the commissioner in her state over issues providers with having with a particular company, the commissioner told them bluntly "I'm not your bill collector". That might give you an idea of what you'd be facing if you go that route. Lastly, a complaint may take considerable time before being reviewed, and your provider shouldn't be delaying attempts to collect this while waiting. All that said, I do know that when a complaint it filed, it can sometimes trigger someone at a higher level in the insurance company to take a closer look at the problem and perhaps give the issue a more serious consideration than you would get from just calling into a phone rep, so that may be the advantage in taking this step.

If your provider is not contracted with this company, it could end up being quite time-consuming and ultimately futile to try to compel them to do anything, and I would definitely recommend going the route of holding the patient responsible for these bills. Collect payment up front if you can. For services already provided, you can explain the situation to the patients, and you can provide coded invoices that they can use to attempt to work with their plan for services on their own. If your physician has performed a service for these patients in good faith and their insurance company refuses to even look at your claims, then the patients are legally and ethically responsible for these bills.

 

[TJAlexander]

I've filed a few claims with the state commissioner's office in GA. Because the plans were self-funded they didn't have jurisdiction however, once the state contacted the payer I usually heard from someone who was able to help me with the issue.

 

[vsmith154]

I used to work for one of the biggest insurance carriers and I can tell you that a State Board complaint will definitely get their attention. I have used that as a last resort when necessary and it has always helped.

 

[NLCrew]

I also have filed a complaint with the commisioner's office. Both the commissioner's office and a person from Humana were able to contact me. I was dealing with trying to get a supplemental co-insurance paid. Humana is the biggest fraudently company I had to deal with since 2021. If you are not in network with insurance companies, you have very limited options. However, if you don't have a contract with the insurance company, then you have unlimited options.

 

[StuC2018]

I have seen complaints go both ways. One situation for which I expected assistance, remained the same. There was another case in which I expected no assistance. The state board gave the insurance company the motivation to 360 their decision. Go figure. I would advise you to state your case. You never know until you try.