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Linder Psychiatric Group, Inc. Child, Adolescent, Adult, and Forensic Psychiatry, Psychology, and Psychotherapy 193 Blue Ravine Road, Suite 170, Folsom, CA. 95630 970 Reserve Drive, Suite 205, Roseville, CA. 95678 Phone (916) 608-0714 Fax: (916) 608-0717 Phone (916) 780 1070 Fax: (916) 780-1199 www.echildpsychiatry.com Email: admin@echildpsychiatry.com |
- HELP FOR UNPAID CLAIMS:
Please note that all claims from LPG are sent certified signed receipt mail and double checked by two employee's. If you are being told that there is "no claim
on file", please contact our staff for the certified receipt tracking number.
1. Don't be fooled or diverted by attempts to make you angry at the party that has not been paid for the services they provided to you. Ask questions, and
control your temper -- the person on the phone is not the problem, but may possibly be your avenue to a solution. Some delays really are administrative
errors that can be easily corrected.
2. Document who you are speaking to (title), when (date and time), where (location), and what department. Don't forget to get the phone number and
extension of the person you are speaking to, and tell them you will call back to follow up in one week.
3. If your claim is not resolved in one week then move up the chain: ask to speak to the supervisor, the Benefits Supervisor, etc. Keep a record of every
person you speak to (first and last name -- "Suzie" is not sufficient), and what you were told.
4. Follow up by sending a letter and then a formal written complaint to the Company's Claim Department, Complaint Department, and CEO. They have thirty
days to resolve your dispute. If it is not resolved with in thirty days you may file a complaint with the Department of Managed Health Care (see link below).
5. Copy our free form letters to send on the HMOhelpletters tab.
6. If you are having difficulty, ask the claims representative to do a three way call with your doctors office for assistance. This is also helpful when the
insurance representative is telling you something different than what has been told to the doctors office.
- YOUR HEALTH CARE RIGHTS:
California Regulators Adopt Rules On Timely Access to Non-Emergency Care
SACRAMENTO, Calif.—Seven years after the enactment of legislation (A.B. 2179) directing it to do so, the California Department of Managed Health Care
(DMHC) announced Jan. 20 it adopted regulations aimed at ensuring plan enrollees have timely access to health care services.
According to DMHC Director Cindy Ehnes, the new rules make California the first state to shorten the time a patient has to wait to see a doctor by requiring
that managed care plans ensure member appointments with medical providers be scheduled within certain time frames. “California patients are literally sick
of having to wait weeks to see a doctor,” Ehnes said in a Jan. 20 statement. DMHC said it receives complaints from managed care plan members having
difficulty getting appointments with doctors, noting a 2009 study found that new patients in preferred provider organizations and health maintenance
organizations wait an average of 59 days to see a family practice physician in Los Angeles. The adoption of the rules follows multiple rounds of public
comment from managed care plans, providers, and consumers through most of last year. The state's Office of Administrative Law (OAL), which oversees
regulatory agency rulemaking, rejected a previous version of the regulations issued Jan. 9, 2009, on the grounds that it provided too little time for public
comment.
In March 2008, OAL also disapproved an earlier set of proposed rules after OAL concluded that by allowing plans to develop their own standards for patient
wait times, they failed to comply with California administrative law requiring regulations to set uniform standard governing all plans.
Time Frames for Appointment Scheduling
The regulations require managed care plans meet the following appointment scheduling time frames:
• urgent care appointments for services that do not require prior authorization within 48 hours of the request for appointment;
• urgent care appointments for services that require prior authorization within 96 hours of the request for appointment;
• non-urgent appointments for primary care within 10 business days of the request for appointment;
• non-urgent appointments with specialist physicians within 15 business days of the request for appointment;
• non-urgent appointments with a nonphysician mental health care provider within 10 business days of the request for appointment; and
• non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition within 15 business days of the
request for appointment.
However, the regulations permit these time frames to be extended if a provider has determined a longer waiting time will not have a detrimental impact on
the health of the patient. The rules also contain an exception for non-urgent services including preventive care and periodic follow-up care.Plans must also provide 24/7 triage
or screening services by telephone with wait times not exceeding 30 minutes.
Telephone triage or screening services can be provided through plan-operated telephonic triage or medical advice services, the plan's contracted primary care and mental
health care provider network, or other means.
Must Ensure Sufficient Numbers of Providers
Under the regulations, managed care plans are required to adopt written quality assurance standards ensuring they have enough contracted providers to comply with the
rules. Plans must draw up compliance monitoring policies and procedures for DMHC review and approval that accurately measure the accessibility and availability of contracted
providers and document network capacity. Plans must also survey providers and enrollees annually to assess compliance with timely access to care standards. Managed care
plans that use a preferred provider organization network may demonstrate compliance with network provider availability requirements by monitoring at least annually the
number of PPO primary care and specialty physicians under contract with the plan in each county of the plan's service area, enrollee grievances and appeals regarding timely
access, and the rates of compliance with the timely access to care standards. The rules also require managed care plans to implement “prompt investigation and corrective
action” when their compliance monitoring determines their provider network is not sufficient to ensure timely member access to care.
‘Groundbreaking Consumer Protections.'
Health Access California, a consumer advocacy coalition that sponsored A.B. 2179 in 2002, noted that while the concept of timely access to health care was
one of the “cornerstones” of the original Knox-Keene Act of 1975 that established and regulated managed care plans in California, it remained largely
unrealized and unenforced. “These ground breaking consumer protections will help ensure that HMO patients get the care they need, when they need it,”
Anthony Wright, executive director of Health Access California, said in a Jan. 20 statement. “Care delayed is often care denied, leading to worse health
outcomes or unnecessary visits to the emergency room,” Wright said. “These new first-in-the-nation patient rights will provide consumers with clear
expectations about how quickly they should get in to see a doctor or specialist.” Plans See Rules as Compromise Patrick Johnston, president of the
California Association of Health Plans, said in a Jan. 20 statement that the regulations represent a compromise between health plans and consumer
concerns. “Health plans felt it was important care strike a balance between ensuring patients don't face unnecessary delays for care and leaving room for
doctors to use their professional judgment in prioritizing patient care,” Johnston stated, noting the rules grant flexibility to prioritize the range of requests
for appointments from urgent to preventative care. “We look forward to working with the state on implementation of these new rules to ensure we streamline
reporting requirements and do not create unnecessary red tape. At the end of the day, we don't want to get in the way of doctors doing their jobs.”
By Frederick L. Pilot The comments and final text of DMHC's Timely Access to Non-Emergency Health Care Services regulations are available at http://wpso.dmhc.ca.
gov/regulations/regs/?key=20.
• You have the right to receive uninterrupted care from your doctor and HMO and to be referred to other health care
providers when necessary.
• You have the right to receive a second opinion when you or your doctor request one.
• You have the right to receive an authorization from your health plan for referral to a specialist within three days.
• You have the right to have your doctor freely discuss your medical treatment options and care with you, without
interference or restrictions by your health plan.
SUMMARY OF YOUR RIGHTS WHEN GETTING NEW INSURANCE:
• If you are joining a group health plan, you have the right to not be denied coverage on the basis of your health status, medical condition or history, genetic
information, disability or insurability. • You have the right to receive coverage for preexisting conditions in most cases within 12 months (or, in some
instances, six months) of enrolling in a group health care plan.
• If you are enrolling in an individual plan, you have the right not to be denied coverage if you have had 18 months of continuous coverage previously and
meet certain other requirements.
• You have the right to be credited for time enrolled in a previous plan against any preexisting condition waiting
period.
In 1996, Congress passed a law known as the Health Insurance Portability and Accountability Act or HIPAA (also known as the Kassebaum-Kennedy Act), which went into effect
on July 1, 1997. HIPAA was designed to allow employees to move freely from one job to another without the risk of becoming uninsured for their most serious health problems.
HIPAA also has protections for individuals who move from a group plan to an individual health plan. In California, there are additional protections for members of group health
plans that go beyond the requirements of HIPAA.
Continuity of Care is receiving health care services without inappropriate disruption even if your provider or plan changes.
WHAT IF I WANT TO SEE A SPECIALIST WHO IS NOT ON MY PANEL?
If there is no doctor within your plan’s network that meets the qualified health care professional standard, then the plan must authorize a second opinion
from someone with the appropriate qualifications from outside of the plan’s network, taking into account your ability to travel to the provider.
WHAT IF NONE OF THE PROVIDERS ON MY INSURANCE PANEL ARE ACCEPTING PATIENTS?
You may request to be reimbursed or have a "single case agreement" set up to see a specialist outside the panel if you find that none of the providers on
your insurance panel are taking patients or returning phone calls. Please see our free letters for assistance.
HOW LONG CAN MY PLAN TAKE TO AUTHORIZE MY REFERRAL TO A SPECIALIST?
When you require a referral to a specialist or specialty care center, your health plan must decide whether or not to authorize the referral within three
business days of the date when you or your primary care physician made the request and submitted all necessary information and medical records. Once your
health plan decides to authorize the referral, the company must make the referral within four business days of when the proposed treatment plan is
submitted to the plan medical director.
Under California law, your health plan must reimburse any doctor who performs any emergency services that you receive to stabilize you. The only time that
a plan is not required to pay for your emergency health care services is when it determines
that you did not require emergency services, and you should have known that an emergency did not exist.
WHAT IF THE DOCTOR YOU WANT TO SEE IS NOT ON YOUR PANEL?
• If you are denied care, ask for it in writing. You will need a record of the denial if you want to dispute it. Memorialize in written correspondence all
conversations if it becomes apparent that you are not receiving cooperation. Leaving a "paper trail" often helps to get results.
• Find out the time lines. Most are included on our web site, but you may find additional assistance from the
National Committee for Quality Assurance [www.ncqa.org], American Accreditation HealthCare Commission/URAC [www.urac.org] and the Joint Commission on
Accreditation of Health Care Organizations [www.jcaho.org].
• Appeal a treatment denial to regulators.
• Find allies in the medical profession. When medical experts advocate care, HMOs find it harder to deny treatment. Insist on a second or third opinion-
from a qualified professional outside the HMO network, if necessary. If your HMO won't pay for a second opinion, pay out of your own pocket. It could save
your life.
Private Insurance:
The majority of working Americans are covered under employer-provided health insurance plans. One type of plan is a standard indemnity policy: people are
free to visit health care providers of their choice and pay out of pocket for their treatment. The insurance plan reimburses members for some portion of the
cost. The other common plan is a managed care plan. Medically necessary care is provided in the most cost-effective - or least expensive - method available.
Plan members must visit health care providers chosen by the managed care plan. Sometimes a copayment is charged to the patient, but generally all care
received from providers within the plan is covered. Recently, managed care companies have begun to provide services in many States for low-income
Medicare and Medicaid beneficiaries.
Both types of health coverage may offer some coverage for mental health treatment. However, this treatment often is not paid for at the same rate as other
health care costs, or there may be limits on visits. A few States have enacted "parity" laws that require insurers to pay for mental health and other health care
costs at the same rate.
For the Uninsured:
If you are not insured, or if your income is limited, you might try other strategies to pay for mental health care. We offer sliding -scale fees based on you and
your spouses income - the provider will reduce his or her fees. Other providers, if they are aware of your financial limitations, may be willing to negotiate a
payment plan that you can afford or to lower their rates according to what your insurance plan pays.
Community-based resources - Many communities have community mental health centers (CMHCs). These centers offer a range of mental health treatment
and counseling services, usually at a reduced rate for low-income people. CMHCs generally require that you have a private insurance plan or be a recipient
of public assistance.
Your church or synagogue can put you in touch with a pastoral counseling program. Certified pastoral counselors, who are ministers in a recognized
religious body and have advanced degrees in pastoral counseling, as well as professional counseling experience. Pastoral counseling is often provided as a
sliding-scale fee.
Self-help groups - Another option is to join a self-help or support group. Such groups give people a chance to learn more, talk about and work on their
common problems-such as alcoholism, substance abuse, depression, family issues, and relationships. Self-help groups are generally free and can be found
in virtually every community in America. They have proven to be very effective.
Public assistance - People with severe mental illness may be eligible for several forms of public assistance, both to meet basic costs of living and to pay for
health care. Such programs include Social Security, Medicare, Medicaid, and disability benefits.
Medicare is America's major Federal health insurance program for some people who are 65 or older and for some with disabilities who are under 65. It
provides basic protection for the cost of health care. Two programs can help people who have low incomes receive benefits. These are the Qualified
Medicare Beneficiary (QMB) and the Specified Low-Income Medicare Beneficiary (SLMB) programs.
Medicaid and Medical pays for some health care costs for America's poorest and most vulnerable people. More information about Medicaid and who is
eligible for it is available at local welfare and medical assistance offices. Although there are certain Federal requirements, each State has its own rules and
regulations for Medicaid.
Helpful Links:
Making A Killing: HMO and the Threat to Your Health
http://www.consumerwatchdog.org/healthcare/
http://www.calpatientguide.org
http://www.mhac.org/
The following resources have been compiled to assist you in getting the care you need:
Department of Managed Health Care
California HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Phone: (888) HMO-2219 or
(800) 400-0815 or
TDD: (877) 688-9891
Fax: (916) 229-0465
http://www.dmhc.ca.gov
Consumer Advocacy Groups. Patients can register complaints with the local chapters of the:
Mental Health America (call 1-800-969-NMHA for local phone numbers) and the National Alliance for the Mentally Ill (call NAMI's Helpline at 1-800-950-NAMI for
local phone numbers of chapters and affiliates).
Foundation for Taxpayer and Consumer Rights. 2000. HMO Patient Self-Defense Kit.
California Consumer Health Care Council
Department of Corporations
980 9th Street, Suite #500
Sacramento, CA 95814-3860
916-445-7205
Consumer Services Unit
800-400-0815
Related Articles/Resources
Making A Killing: The HMO Threat To Your Health
Dealing With Kaiser and Other HMO's
Foundation for Taxpayer and Consumer Rights
http://www.calpatientguide.org
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