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Legal guidance for Calif. patients facing insurance denials

June 22, 2012
by Gary A. Enos, Editor
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Attorneys will contact insurers on patients' behalf
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 Patients in some California addiction treatment centers now have access to a possible legal tool if they encounter tussles with their health insurance company over getting the treatment stay they appear to need.

California facilities that belong to the California Treatment Advocacy Foundation are financing a free initial consultation with one of two attorneys (one based in Southern California, one in Northern California) for patients experiencing what appears to be an unwarranted denial of care. Based on the facts of each situation, the attorneys will contact the insurer on the patient’s belief to see if the matter can be resolved.

“We’ll contact the insurance provider and ask, ‘Can you take another look at this?’” says Phillip Greer, the California Treatment Advocacy Foundation’s executive director and one of the two participating attorneys. Greer expects the initial process to unfold over three to four days, after which the patient and his/her legal adviser could consider pursuing further action if a dispute with the insurer persists.

Greer says the launch of this legal referral service does not reflect any perception among California treatment centers that insurance denials are spiking at the moment. It simply serves as a strategy that facilities are pursuing as they have come together recently under a new association umbrella, he says. Greer says the foundation represents about 25 to 30 treatment centers that accept insurance payment.

According to Greer, the situations he will examine will involve instances in which it appears that insurers are not following the terms of their own policies and contracts. The factors he will have to analyze in each case are the nature and extent of the patient’s insurance coverage and the nature of the services that the facility is attempting to provide.

“There are always going to be excuses from the carriers to the providers, but when the individual patient gets involved, you’re talking about people not getting the services they need and the services they pay for,” says Greer.

He believes that public pressure on insurers in these cases could result in resolutions to several of these types of conflicts before they officially enter the legal process.

Greer says he considers regulatory protections for Californians trying to access substance use treatment to be relatively weak, and one development that many in the community would like to see is adoption of comprehensive state parity legislation. Advocates in the state continue to monitor the progress of AB 154, a bill that would expand insurance coverage and parity mandates for behavioral health benefits. That bill has been sitting in a Senate health committee at a time when state legislators have been busy responding to California’s severe budget crisis.

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Buying groceries is something that's natural.  You balance the ingredients, costs, and traits.  However, exceedingly few persons consider themselves as competent when they're buying health insurance -- and it shows in the charges they pay.

Health care reform will eventually bring another 30 million Americans into the insurance shopping arena.  Even if you're not one of those individuals, you ought to understand how to shop for health insurance.   Understand what the factors  are, what affects the rates -- for instance, the deductible.

If you're going to the doctor sporadically -- once or twice annually and have one prescription, there is no need for you to have a highly expensive, exceedingly minimal deductible plan.  So presuming you mean to keep your fees at a minimum, maintain a high deductible.

Another notable feature is the association -- the pool of clinicians, hospitals, and drugstores that are contracted with the health insurance company administering your policy.  Similarly important -- especially if you've got a high deductible -- are the rebates your health insurance company secures for you in that group.

Another chief component:  your stop loss -- i.e., the maximum exposure that the patient has out-of-pocket, before he's no longer responsible for any additional out-of-pocket fees. At the end of the day -- if you're the one paying for it, you already know that health insurance costs a ton of money.  That's why you've got to understand it and specially know how to shop for it.