In developing benefit plans and reporting inappropriate actions of insurers, the patient is often the most effective advocate. The main area of oversight of Departments of Insurance around the country is to protect the consumer (the patient). Employers have a vested interest in ensuring the health and safety of their employees. ACA has developed resources to assist patients in advocating for appropriate care and putting a stop to unfair insurer practices which put patients at risk.
Increasing/Requesting Chiropractic Benefits
If you have no chiropractic coverage through your health plan or are interested in requesting an increase in your chiropractic benefits, contact human resources. You should inquire when determinations regarding health benefits are made and report concerns and suggestions to the human resources manager or benefits administrator. If you do not know who would be the appropriate person, you should inquire with management to determine who makes decisions regarding employee benefits.
Depending on the type of health care coverage you have, there are different ways to lodge a complaint against an insurance company. A good starting point for determining your next step, is to find out if your health benefit is regulated by the Employee Retirement Income Security Act (ERISA). Determining whether you have an ERISA plan can be difficult – many of the same networks are contracted by ERISA and non-ERISA plans. To determine whether you are covered by an ERISA plan, determine if your plan is provided by a private employer; if so, the plan is an ERISA plan. ERISA regulations only cover plans provided by private employers; therefore, non-private employer plans are not covered under ERISA regulations.
Non-private plans are provided by:
- State or Federal Government Agencies.
- Public Schools.
- Workers’ Compensation.
- Individual health plans for people who are self-employed or are not employed by a private employer.
Patients whose health plan is subject to ERISA have certain rights. If you have a health plan governed by ERISA and you have been notified that a claim has been denied, according to the Department of Labor, the plan administrator must tell you how to submit the denied claim for a full and fair review. You have at least 60 days to request a review. Step-by-step instructions for beneficiaries to appeal denials are available here. A general overview of ERISA is accessible here.
Contact Your Department of Insurance
If your plan is not covered by ERISA, send contact you State Departments of Insurance (DOI). DOIs are obligated to investigate complaints reported by consumers. Many DOIs have set up easy to use online forms for reporting concerns/complaints. Some examples of appropriate times to report concerns to Departments of Insurance include; delays in payment, conflicts between described benefits and benefits rendered, and communication problems with insurers. If you have any concerns with an insurance company, report those concerns to your local DOI.
Give Us Your Feedback
There is a growing concern in the chiropractic community regarding insurers’ use of third party administrators and provider networks. These networks have been requiring chiropractic patients to complete burdensome paperwork, inappropriately denying benefits and limiting patient access to medically necessary care. If you think your insurer is using one of these networks, and you would like to share your thoughts on this issue, please contact ACA.