If you have questions about the practices of your managed-care coverage, ask the experts at the Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
My daughter was injured in an accident in January 2006 and has required numerous medical procedures. We have made every effort to pay our portion of every bill.
This has been a daunting task, however, because our insurance carrier has been less than honorable in paying their portion. Even though the initial accident was considered an emergency, our insurance company refused to pay the providers.
After many calls, they paid some of the bills, but others ended up in a collection agency. I paid some of the bills just to protect my daughter's credit.
Now, after I finally believed that I was through with all this, I received another bill that is over two years old! My family already met its out-of-pocket expenses for 2006, so shouldn't whatever amount is due for these services be the responsibility of our insurance company?
– Melinda Gardner, El Dorado Hills
Payment disputes like yours are among the most frequently submitted complaints to the Department of Managed Health Care yearly.
In 2007, we found that almost 40 percent of all health plan member complaints arose from some form of billing, claims, co-payment or financial dispute.
Medical providers, too, contact the department about billing disputes. The Provider Complaint Unit assists doctors, hospitals, and other health care providers to resolve their claims disputes.
To date, the Provider Complaint Unit has recovered more than $9 million in additional payments for providers.
Payment problems occur for many reasons, including human error, a problem in the plan's billing system or a dispute between the provider and the health plan over the amount to be paid.
Typically, it should not take two years for a claim to be resolved. In your case, filing a complaint with the health plan resolved your problem, and the health plan agreed to pay the claim.
If you have a question about why a claim was not paid or whether the claim is covered, call the plan's member services department or discuss the problem with the provider's billing office.
If the issue is not resolved, file a complaint with the health plan. It then has up to 30 days to resolve it. If it takes longer or does not satisfactorily resolve the matter, file a complaint with the DMHC's Help Center.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
