Has a health plan denied payment, or refused to cover treatment you felt was necessary? Or just not responded, so you haven’t been able to resolve a coverage or payment issue?  You may feel desperate and stuck.  But there is one card you probably haven’t played: Reaching out to your state government for help.

If a health plan denies payment, refuses to cover medically necessary or emergency treatment, or even refuses to cover experimental or investigational treatment, a client or provider can reach out for assistance to their state Department of Insurance — the DOI.  In addition, California has the Department of Managed Health Care, the DMHC, which oversees some plans.

These state agencies exist to help clients get the health care they deserve.  Each state’s DOI operates differently, but you may be able to get advice from their consumer helpline.  You may be able to file a complaint.  You may also be able to apply for some type of Independent Medical Review, where Independent providers review the case, and the health plan must follow their determination.  You may even be able to ask for an expedited review if the case requires a quick coverage determination.

You may think that the chances of getting help from the state is small and isn’t worth your effort.  But many providers report the advice they received from the DOI helplines has been very useful.  And check out the statistics in your state.  For example, the California DMHC reports that approximately 68% of clients who file for an Independent Medical Review receive their requested treatment from their health plan.

Sometimes, when a health plan receives a letter from the state, it is just the kick in the butt that is needed.  I have filed two complaints online at the California DMHC website.  In both cases, the state sent a letter to the health plan, and I suddenly got the payment that I had been fighting for months to receive.

A few recommendations:

• Create a chronological list of efforts you made to resolve the issue. Document every call you make or email you send.  Document who you talked to and when, and what they said.  Get call confirmation numbers.
• Look at the client’s card. Is the health plan an out-of-state plan (e.g. Blue Cross of Georgia, and you and the client are in Kansas?)  If so, you might need to contact the DOI where the plan is located.
• Read all the info on the DOI’s website first and develop a list of questions. Then contact the DOI or DMHC BY PHONE to get advice about your case before filing your complaint or request for review.  Be sure to talk to someone in the health insurance department.
  • To help with this, I’ve compiled a list of each state DOI’s contact information – click here
  • Confirm with them that they have jurisdiction over the health plan you are dealing with (ex. in California, plans are divided between the DOI and the DMHC)
  • They may say you must exhaust all the appeals at the health plan before coming to them. However, if you need an expedited answer from the plan due to a client’s situation, or the health plan has not been responsive, you may be able to bypass this
  • Know that a few DOIs will only accept complaints from clients.
  • Most states will not get involved if an attorney is involved in the case, so contact the state first
• You will need to get a release from the client to file the complaint or to apply for an independent review, unless the client is filing.
• These state departments primarily exist to help clients, not so much to help therapists get paid. So, you may need to file complaints under a client’s name.  When possible, highlight how the non-payment is negatively impacting the client’s access to care.

One final thought:  Just filing a complaint against a health plan can help in other ways.  Complaint statistics (ex. the number of complaints filed against a health plan, or number of plan denials overturned) can be used in many ways to track bad behavior by health plans, including in lawsuits against those plans.  Politicians can also use these statistics and observed denial patterns to draft helpful legislation to protect clients and providers. Some states publicize these statistics to rank health plans and help clients choose a plan (for an example, see New York’s guide click here)