Does filing a complaint with the insurance commissioner do any good?

The primary function of the Office of the Commissioner of Insurance (OCI) is to regulate the insurance industry. Most of their work deals with administering financial and statutory compliance activities. OCI also has an obligation to enforce the insurance laws that regulate the methods in which insurers pay claims.

For the vast majority of patient or doctor complaints, OCI serves merely as a communications conduit. The doctor or patient fills out a complaint form (these may be obtained by calling OCI or at their website), OCI sends a copy of the complaint to the insurer, the insurer responds to OCI, and OCI sends a copy of their response to the person making the complaint.

This process is often successful because insurers are very sensitive to receiving complaints from OCI. Receiving a complaint focuses their attention on the problem and, at the very least, the doctor or patient get a definitive answer to their complaint. If you or your patients believe the insurer is violating a law, you could file a complaint with OCI; however, a better course of action would be to inform the WCA of the potential violation so we can file a complaint on your behalf. The WCA has the advantage of grouping similar complaints together to get a better quality response from the insurance commissioner’s office.

What insurance laws or rules is the insurance commissioner supposed to enforce?

Most of the laws and rules that are enforced by the insurance commissioner’s office relate to the financial regulation of insurance companies. There are, however, administrative rules related to the claims settlement practices of insurers that the insurance commissioner enforces. These rules are necessary because insurance is a very complicated business. Unless someone is employed by the insurance industry, it is almost impossible to decipher the language in a policy. The continuous policy amendments a patient receives are usually ignored until they have a serious health problem – and by then it is usually too late. To bring some fairness into the system, the state has rules about how a claim must be processed.

It is an unfair insurance practice if an insurer fails to promptly acknowledge pertinent communications with respect to claims policies. Could you please provide some practical examples of this problem?

Here are some practical examples:

• An insurer claims that chiropractic services are not a covered benefit under the patient’s insurance policy but refuses to provide written proof of the exclusion.

• An insurer refuses to pay for some chiropractic services and will not provide a written explanation for its denial.

• An insurer refuses to pay for chiropractic care rendered to a child and will not provide a written explanation for its denial.

It is an unfair insurance practice if an insurer fails to initiate and conclude a claims investigation with all reasonable dispatch. Could you please provide some practical examples of this problem?

Here are some practical examples:

• An insurer acknowledges receiving a claim from a chiropractor but refuses to process the claim. Note: it is the responsibility of the provider to follow up on a claim that has been submitted.

• An insurer requests that an independent medical exam (IME) be done on a patient but does not schedule the exam promptly or excessively delays the report of the IME doctor. Note: Since the rule does not define “reasonable”, it is up to the provider to follow up and document what they believe to be unnecessary delays before they file a complaint with the insurance commissioner’s office.

It is an unfair insurance practice if an insurer fails, upon request of a claimant, to promptly provide a reasonable explanation of the basis in the policy contract or applicable law for denial of a claim or for the offer of a compromise settlement. Could you please provide some practical examples of this problem?

Here are some practical examples:

• The reason most insurers give for denying reimbursement for services is that the care did not meet the definition of “medical necessity” in the policy. Merely stating the policy terms is not the reasonable explanation required under this rule and Wi. Stat. 832.87.

• In personal injury cases, the insurer is required to give an explanation as to why they are unwilling to pay for all of the health care services rendered to the patient.

It is an unfair insurance practice if an insurer knowingly misrepresents to claimants pertinent facts or policy provisions relating to coverages involved. Could you please provide some practical examples of this problem?

Here are some practical examples:

• An insurer that requires pre-authorization of chiropractic services but does not require pre-authorization from other health care providers for similar types of care.

• An insurer that arbitrarily limits a patient to a certain number of adjustments services but does not limit other health care providers for similar types of care.

• An insurer that repeatedly gives out inaccurate information about a patient’s insurance benefits.

It is an unfair insurance practice if an insurer fails to affirm or deny coverage of claims within a reasonable time after proof of loss has been completed. Could you please provide a practical example of this problem?

An insurer that acknowledges receipt of a claim but does not respond in any way within 30 days.

It is an unfair insurance practice if an insurer, except as may be otherwise provided in the policy contract, fails to offer settlement under applicable first party coverage on the basis that responsibility for payment should be assumed by other persons or insurers. Could you please a practical example of this problem?

An insurer that refuses to make payments under the medical payments portion of the policy claiming that chiropractic services should be paid for by the “at fault” party.

It is an unfair insurance practice if an insurer refuses payment of claims solely on the basis of the insured’s request to do so without making an independent evaluation of the insured’s liability based upon all available information. Could you please provide a practical example of this problem?

This rarely occurs with group health claims and, if an insurer is obstinate in a personal injury case, the patient would normally seek legal counsel.

It is an unfair insurance practice if an insurer fails to adopt or make known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration. Could you please provide a practical example of this problem?

This violation would occur in personal injury cases and is not likely involve a chiropractor.

It is an unfair insurance practice if an insurer fails, when appropriate, to make use of arbitration procedures authorized or permitted under any insurance policy. Could you please provide a practical example of this problem?

A group health insurer that refuses to allow a patient access to the appeal processes described in their policies.

It is an unfair insurance practice if an insurer fails to make provision for adequate claims handling personnel, systems, and procedures to effectively service claims incurred under insurance coverage issued or delivered in this state. Could you please provide some practical examples of this problem?

Here are some practical examples:

• A group health carrier that delays payment because it is having computer problems.
• A group health carrier that delays payment because it has a shortage of customer service personnel.

 

It is an unfair insurance practice if an insurer fails to adopt reasonable standards for investigation of claims arising under its insurance policies. Could you please provide a practical example of this problem?

While this problem can definitely affect chiropractors, it is not a violation that is easily detectable because the insurance company will not tell you what their procedures are for investigating a claim. The insurance commissioner’s office would have to investigate this rule violation.

 

Why doesn’t the insurance commissioner more aggressively defend patients that are taken advantage of by their insurance companies?

While the Office of the Commissioner of Insurance is a regulatory agency, it does not get significantly involved in patient complaints unless it is clear that a law has been broken. Patients may believe that if an insurer refuses to pay their claim stating that the care was not “medically necessary”, that the insurer has broken the law. Unfortunately, this is not true.

All health care policies have a clause that states that the insurance company has the right to review the clinical documentation of the doctor to determine if the care was necessary. If they did not have this clause, a patient could submit a claim for any service rendered by a health care professional and expect to have the claim paid. Insurers would quickly go broke and there would be no more insurance benefits. Patients and their doctors now have the external review process available to them if they believe a medical necessity determination was wrong.

The insurance commissioner’s office limits their initial involvement to sending a copy of the patient’s complaint to the insurer and asking for a response within 20 days. Then, they forward the response of the insurer to the patient. The commissioner’s office takes no further action unless the patient alleges that the insurance company broke a specific law, cites the law that was allegedly broken, and provides evidence of the violation.

When a WCA member suspects an insurance company broke the law, the WCA can often resolve the matter by writing to the insurer and, if necessary, file a complaint with the insurance commissioner’s office. Because the WCA sees complaints from across the state, it can combine violations to make a bigger impact at the commissioner’s office.

How much may we charge to attorneys that request our records?

You may charge an attorney no more than the following fees for supplying certified duplicate health care provider records:

• For records displayed on paper medium, the greater of $8.40 per request; or, 45 cents per record page for the first 50 pages, and 25 cents per record page over 50 pages.
• $4.00 per X-ray copy
• The actual costs of postage or other means of delivering the requested duplicate records to the attorney.

Does a separate charge apply to each request?

Yes. You may bill for records every time you submit records to a worker’s compensation carrier or an attorney.

 

Can I charge more than the amounts listed and charge the balance to the patient?

No. The amounts listed are the maximum that can be charged.

What information must an attorney give me with their request for a copy of the patient’s records?

• The correct name of the patient
• The patient’s social security number, if known
• The patient’s date of birth, if known
• A description of the records requested
• The written informed consent of the patient or person authorized by the patient to give consent to release of the records.

Am I better off joining a bad managed care plan just to get “my foot in the door”?

Managed care companies do not base their selection criteria on the quality of your other managed care relationships. Joining a “bad plan” will not help you gain acceptance into a “good plan”.

When a managed care plan adds providers, must they accept those that applied first?

No. They are free to add providers in any manner they choose.

Is a managed care plan discriminating if they do not have a female chiropractor on their panel?

While there is not a law requiring representation on a managed care panel by female chiropractors, a managed care plan would be foolish to overlook the health care needs of their female subscribers. In areas that previously have had all male providers, it is not unusual for managed care companies to look past more experienced or qualified male chiropractors to add female chiropractors to their panels.

How true is it when a managed care company states “we do not negotiate because all of our agreements are the same”?

It is in a managed care company’s financial interest to have as many chiropractors as possible sign their contract without negotiating its terms. When a managed care company does not have enough providers that will accept its terms, it has several options at its disposal including opening the contract to more providers, negotiating the terms of the contract, or changing the coverage area it offers to employers. Depending on market conditions, a managed care company may negotiate freely or be virtually inflexible in its terms.

Under what circumstances may a physical therapist bill using a chiropractor’s provider number?

A physical therapist may only use a chiropractor’s provider number if he/she is an employee of the chiropractor.

Can an insurer bundle your xray codes when you bill them separately?

While an insurance company may bundle x-rays codes that were billed separately, you have a right to appeal the decision. To be successful, your appeal must explain the clinical necessity for each x-ray and, more importantly, why you could not have gotten the clinical information necessary to diagnose the patient’s condition from the single x-ray view suggested by the insurer.

Can an insurer change the adjustment code billed by the provider?

You have the right to appeal the decision of the insurer to change your CMT code. To be successful, you must explain the clinical necessity of the code you have chosen and support it by documenting at least two objective findings in each area that was adjusted. If you reach an impasse with the insurer, you have the right to use the external reveiw process or to balance bill the patient.

We get one request after the next from insurance companies requesting records, notes, treatment plans and exam findings. Is there a limit as to how much documentation they can request?

No. It may seem like harassment to you, but an insurance company is allowed to ask for every record generated on behalf of a patient to determine if reimbursement is required under the terms of the patient’s insurance policy. Insurance companies know these requests drive up the cost of care because you must either hire more staff or see fewer patients.

We prefer that insurance companies fax us a list of the documentation they need; however, many companies will only provide the information by phone. Must we comply with their telephone requests or may we insist they put their request in writing?

You are not required to do anything an insurance company requests of you. However, they have your money. If you do not wish to comply with their request, you have the option to collect from your patient who, in turn, will have to seek reimbursement from the insurer. That option usually leads to more frustration than working with the insurer.

One of our biggest frustrations is getting inconsistent answers from an insurance company. For example, our patient will call the insurer and be told they have no copayment and, when we call, we are told the co-payment is $15.00. We have the same type of problem in getting straight answers about deductibles and coverage levels. How do we deal with this problem?

When you or the patient calls to verify their benefits, the individual providing you with that information is supposed to check the patient’s policy number against a computerized database which lists the benefits for the policy. A lazy customer service person will recite the benefits from memory and will not bother to check the database. This laziness leads to inaccurate information being given to you.

A second problem is that policy numbers are often similar. If the wrong policy number is entered into the database, you will receive inaccurate information. A third problem is that large companies may have a number of different insurance options for their employees. If the customer service representative is working from memory instead of checking the database you, once again, get misinformation.

Your first way of protecting yourself is to ask the customer service representative if the would verify the information with the database. If you are not successful with that approach, your only option is to ask for their supervisor, give the supervisor both sets of information along with the names of the individuals providing the information and ask the supervisor to provide accurate benefit information.

 

My patient is leaving her job. Does she have the right to continue her health care coverage?

The federal “COBRA” laws allows most employees, spouses, and their dependents who lose their health coverage under an employer’s group health plan to continue coverage, at their own expense, for a period of time. This law applies to both insured health plans, self-funded plans and those plans sponsored by state and local governments. However, COBRA does not apply to certain church plans, plans covering less than 20 employees, and plans covering federal employees.

Under COBRA, employees who terminate employment for any reason other than gross misconduct, or who lose their eligibility for group coverage because of a reduction in work hours, and the covered spouses and dependents of the employees may continue the group coverage for up to 18 months. A spouse and dependents may continue coverage for up to 36 months if they lose coverage due to the death of the employee, divorce from the employee, loss of dependent status due to age, or due to the employee’s eligibility for Medicare.

My doctor offered a great health policy but I was laid off because of business problems with the practice. May I continue coverage under COBRA even if I go to work for a different employer?

Yes, but only if your new employer’s coverage is not similar to your former employer’s coverage. Coverage is not “similar” if you are subject to any preexisting condition waiting period, if the new employer’s coverage provides substantially different benefits, or if it is more costly.

We are a large practice with more than 20 employees. Are we, or the insurance company, responsible for notifying our employees of their right to continuation or conversion coverage?

You are responsible for providing your employees with written notice of their right to continue group coverage or convert to an individual policy and the premiums required for each, including the manner, place, and time in which the payments must be made, within 5 days of their loss of group coverage.

How long does a terminated employee have to make a decision about continuing group coverage or converting to an individual policy?

The employee has 30 days from the date they are given notice of their continuation and conversion rights to make their decision and pay the required premium for coverage.

Are continuation or conversion rights available if a group policy terminates because a chiropractor goes out of business?

Normally, continuation rights are not available when an employer goes out of business because the employer’s group health insurance policy is no longer effective. In such cases, employees are left only with the option to convert to an individual policy.

What happens if we change insurance companies or change our health insurance benefits while an exemployee is on continuation?

If you change insurance companies, the ex-employee will be covered under the new group insurance policy until the end of the 18-month continuation period as long the exemployee remains eligible. If you change policy benefits, the ex-employee will receive the same benefits available to all active employees.

Are we required to give our employees a certain amount of notice if a decision is made to change insurance companies or to change the benefits under our existing insurance plan?

No. Wisconsin law does not require that the employer notify their employees within a certain time of changes to the group insurance plan.

What is a “closed panel” plan?

A “closed panel” plan is a type of health plan that requires enrollees to seek care from a provider who is either employed by or under contract to the health maintenance organization or limited service health organization.

 

What is a “defined network plan”?

A “defined network plan” is any health benefit plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the plan. This type of plan is often referred to as a managed care plan.

What is a “health maintenance organization (HMO)”?

A health maintenance organization (HMO) is a health care financing and delivery system that provides comprehensive health care services in a particular geographic area. An HMO provides comprehensive, prepaid medical care. It differs from a traditional insurer because it both pays for and provides the medical care. Persons insured by an HMO plan are referred to as enrollees. In contrast to a traditional health insurance plan, an HMO generally operates on a closed-panel basis. This means that enrollees are required to seek care from a medical provider who is either employed by or under contract to the HMO.

HMOs limit care to a specific geographic area. Except for serious emergencies or the need for urgent care outside the service area, the HMO will probably not pay for care that enrollees receive from a provider who is not affiliated with the HMO unless the HMO physician refers an enrollee to that provider.

What is an “individual practice association (IPA)”?

An “individual practice association (IPA)” is an association of providers that contract with a health maintenance organization, limited service health organization, or preferred provider plan to provide health care services.

What is a “limited service health organizations (LSHO)”?

A “limited service health organizations (LSHO) is a health care plan that makes available to its enrollees a limited range of health care services, such as dental or eye care, performed by providers selected by the organization.

What is a “managed care plan”?

A managed care plan is any health plan that requires or creates incentives for an enrollee to use providers that are owned, managed, or under contract with the insurer offering the health benefit plan.

What is an “open panel” plan?

An open panel plan is a type of health plan than generally allows any provider to offer services to its enrollees and provides incentives for the enrollee to use providers selected by the plan.

 

What is a preferred provider plan (PPP)”?

A preferred provider plan (PPP) is a health care plan that makes available to its enrollees either comprehensive health care services or a limited range of health care services performed by providers selected by the plan. It allows enrollees to use providers outside the network, but enrollees may be liable for a significant portion of these claims. A PPP pays a specific level of benefits if certain providers are used and a lesser amount if non-PPP providers are utilized.

What is “coinsurance”?

Coinsurance is a provision in insurance policies that requires the enrollee to pay a percentage of all eligible health care expenses, in excess of the deductible.

What is a “copayment”?

A copayment is a provision in insurance policies that requires the enrollee to pay a flat fee for certain medical services.

What is a “deductible”?

A deductible is the portion of eligible medical expenses that the enrollee must pay before the plan will make any benefit payments.

What is the “Health Insurance Risk-Sharing Plan (HIRSP)”?

The state legislature recognized that certain individuals, because of their health problems, are unable to secure health insurance through the private market. For that reason, it created the Health Insurance Risk-Sharing Plan (HIRSP) in 1980.

To be eligible for application to HIRSP, an individual must have received, because of some health condition, one of the following within nine months prior to application:

• a notice of rejection or cancellation from one or more health insurers
• a notice of a substantial reduction in benefits
• a notice of premium increase 50% above the standard rate.

In 1998, HIRSP was expanded to include a new group of eligible individuals. Eligible individuals are those who meet all of the following:

• they have at least 18 months of prior insurance coverage and
• have no break in coverage longer than 63 days and
• their most recent coverage is employer-sponsored group coverage and
• they have exhausted all their continuation coverage.

Must we accept HIRSP’s automatic fee discount?

Yes. If you accept a HIRSP patient, you must accept the fee as payment in full. The patient may not be balanced billed.

What is BadgerCare?

BadgerCare is a program to assist lower income, working families obtain health insurance at a reasonable price. To be eligible, a person must meet all of the following criteria:

• Children under age 19 are covered if they live with a parent and
• Income must be under 185% of the federal poverty level for the family and
• The individual must not be covered by any other health insurance.

Premiums are generally zero if the family’s income is less than 150% of the federal poverty level, but in no event will premiums exceed 3% of the family’s income.

We are considering whether or not to offer a health plan to our employees. If we do so, must we offer the plan to all employees?

Neither state of federal law requires an employer to offer health insurance for employees. But, if an employer decides to offer health insurance to employees, both state law and federal law impose certain requirements. An insurer that offers coverage to an employer group must offer coverage to all eligible employees regardless of the employee’s health condition. You may establish eligibility requirements are long as they are not discriminatory. For example, full time employees may receive health benefits, while part-time employees may be excluded.

Premiums are generally zero if the family’s income is less than 150% of the federal poverty level, but in no event will premiums exceed 3% of the family’s income.

What HMOs operate throughout Wisconsin?

Here is a listing of each HMO operating in every county in Wisconsin.

Adams Dean Health Plan, Inc.
Security Health Plan of Wisconsin, Inc.
Unity Health Plans Insurance Corporation
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Ashland Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Medica Health Plans of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
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Barron Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Medica Health Plans of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Bayfield Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Medica Health Plans of Wisconsin, Inc.
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Brown Compcare Health Services Insurance Corporation
Network Health Plan of Wisconsin, Inc.
PHP Insurance Plan, Inc.
Touchpoint Health Plan, Inc.
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Buffalo Atrium Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Valley Health Plan, Inc.
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Burnett Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Medica Health Plans of Wisconsin, Inc.
Valley Health Plan, Inc.
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Calumet Network Health Plan of Wisconsin, Inc.
Touchpoint Health Plan, Inc.
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Chippewa Atrium Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Managed Health Services Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Clark Compcare Health Services Insurance Corporation
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Managed Health Services Insurance Corp.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Columbia Dean Health Plan, Inc.
Group Health Cooperative of South Central Wisconsin
Physicians Plus Insurance Corporation
Unity Health Plans Insurance Corporation
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Crawford Atrium Health Plan, Inc.
Dean Health Plan, Inc.
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Medical Associates Clinic Health Plan of Wisconsin
Unity Health Plans Insurance Corporation
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Dane Dean Health Plan, Inc.
Group Health Cooperative of South Central Wisconsin
MercyCare Insurance Company
Physicians Plus Insurance Corporation
Unity Health Plans Insurance Corporation
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Dodge Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of South Central Wisconsin
Humana Wisconsin Health Organization Insurance Corp.
Managed Health Services Insurance Corp.
Network Health Plan of Wisconsin, Inc.
Physicians Plus Insurance Corporation
United Healthcare of Wisconsin, Inc.
Unity Health Plans Insurance Corporation
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Door PHP Insurance Plan, Inc.
Touchpoint Health Plan, Inc.
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Douglas Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Humana Wisconsin Health Organization Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
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Dunn Atrium Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Humana Wisconsin Health Organization Insurance Corp.
Managed Health Services Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Eau Claire Atrium Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Humana Wisconsin Health Organization Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Florence Compcare Health Services Insurance Corporation
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Fond du Lac Compcare Health Services Insurance Corporation
Dean Health Plan, Inc.
Humana Wisconsin Health Organization Insurance Corp.
Network Health Plan of Wisconsin, Inc.
Touchpoint Health Plan, Inc.
Unity Health Plans Insurance Corporation
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Forest Compcare Health Services Insurance Corporationv Security Health Plan of Wisconsin, Inc.
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Grant Atrium Health Plan, Inc.
Dean Health Plan, Inc.
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Medical Associates Clinic Health Plan of Wisconsin
Unity Health Plans Insurance Corporation
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Green Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Humana Wisconsin Health Organization Insurance Corp.
MercyCare Insurance Company
Physicians Plus Insurance Corporation
Unity Health Plans Insurance Corporation
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Green Lake Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Network Health Plan of Wisconsin, Inc.
Touchpoint Health Plan, Inc.
Unity Health Plans Insurance Corporation
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Iowa Dean Health Plan, Inc.
Group Health Cooperative of South Central Wisconsin
Medical Associates Clinic Health Plan of Wisconsin
Physicians Plus Insurance Corporation
Unity Health Plans Insurance Corporation
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Iron Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Security Health Plan of Wisconsin, Inc.
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Jackson Atrium Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Managed Health Services Insurance Corp.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Jefferson Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Humana Wisconsin Health Organization Insurance Corp.
Managed Health Services Insurance Corp.
MercyCare Insurance Company
Physicians Plus Insurance Corporation
United Healthcare of Wisconsin, Inc.
Unity Health Plans Insurance Corporation
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Juneau Atrium Health Plan, Inc.
Dean Health Plan, Inc.
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Security Health Plan of Wisconsin, Inc.
Unity Health Plans Insurance Corporation
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Kenosha Compcare Health Services Insurance Corporation
Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Humana Wisconsin Health Organization Insurance Corp.
Managed Health Services Insurance Corp.
United Healthcare of Wisconsin, Inc.
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Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Pierce Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Humana Wisconsin Health Organization Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
Valley Health Plan, Inc.
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Polk Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Humana Wisconsin Health Organization Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
Valley Health Plan, Inc.
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Portage Compcare Health Services Insurance Corporation
Emphesys Wisconsin Insurance Company
Managed Health Services Insurance Corp.
Network Health Plan of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Touchpoint Health Plan, Inc.
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Price Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Security Health Plan of Wisconsin, Inc.
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Racine Compcare Health Services Insurance Corporation
Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Humana Wisconsin Health Organization Insurance Corp.
Managed Health Services Insurance Corp.
United Healthcare of Wisconsin, Inc.
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Richland Atrium Health Plan, Inc.
Dean Health Plan, Inc.
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Unity Health Plans Insurance Corporation
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Rock Compcare Health Services Insurance Corporation
Dean Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Humana Wisconsin Health Organization Insurance Corp.
Managed Health Services Insurance Corp.
MercyCare Insurance Company
Physicians Plus Insurance Corporation
Unity Health Plans Insurance Corporation
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Rusk Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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St Croix Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Humana Wisconsin Health Organization Insurance Corp.
Medica Health Plans of Wisconsin, Inc.
Valley Health Plan, Inc.
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Sauk Dean Health Plan, Inc.
Group Health Cooperative of South Central Wisconsin
Physicians Plus Insurance Corporation
Unity Health Plans Insurance Corporation
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Sawyer Atrium Health Plan, Inc.
Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Medica Health Plans of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Shawano Compcare Health Services Insurance Corporation
Managed Health Services Insurance Corp.
Network Health Plan of Wisconsin, Inc.
Security Health Plan of Wisconsin, Inc.
Touchpoint Health Plan, Inc.
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Sheboygan Compcare Health Services Insurance Corporation
Humana Wisconsin Health Organization Insurance Corp.
Network Health Plan of Wisconsin, Inc.
United Healthcare of Wisconsin, Inc.
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Taylor Compcare Health Services Insurance Corporation
Group Health Cooperative of Eau Claire
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.
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Trempealeau Atrium Health Plan, Inc.
Emphesys Wisconsin Insurance Company
Group Health Cooperative of Eau Claire
Gundersen Lutheran Health Plan, Inc.
Health Tradition Health Plan
Security Health Plan of Wisconsin, Inc.
Valley Health Plan, Inc.

 

It is an unfair insurance practice if an insurer fails to promptly provide necessary claims forms, instructions and reasonable assistance to insurance and claimants under its insurance policies. Could you please provide a practical example of this problem?

Since most group health claims are filed directly by a chiropractor on behalf of their patients, this rule rarely comes into play. However, it could have significance if a staff person regularly called an insurer to confirm the patient’s chiropractic benefits and were repeatedly given inaccurate information.

It is an unfair insurance practice if an insurer fails to settle a claim under one portion of the policy coverage in order to influence a settlement under another portion of the policy coverage. Could you please provide a practical example of this problem?

This will typically occur in personal injury cases where the insurer wants a “package deal” in order to settle the entire claim at one time. If the patient has benefits under the medical payments portion of the policy, they are entitled to have these claims paid, up to the limits of the policy, without having to wait for settlement of their claims under different potions of the policy.

It is an unfair insurance practice if an insurer fails to attempt in good faith to effectuate fair and equitable settlement of claims submitted in which liability has become reasonably clear. Could you please provide a practical example of this problem?

This has potential significance in personal injury cases, especially when the patient is not represented by legal counsel. When liability has been admitted, an insurance company must process the patient’s health care claims. They can not threaten to hold up payment of the claims until the patient accepts partial reimbursement for the services rendered.

It is an unfair insurance practice if an insurer compels insureds and claimants to institute suits to recover amounts due under its policies by offering substantially less than the amounts ultimately recovered in suits brought by them. Could you please provide a practical example of this problem?

In personal injury cases, it is often necessary for a patient to retain legal counsel in order to obtain the benefits that are due to them. This type of violation is usually discovered by a chiropractor because they see an entire range of cases covered by one insurer while a patient is only familiar with their own case.

Can we bill our services to an insurance company if our doctor chooses not to keep the level of clinical documentation required by the insurer?

Yes. The billing for chiropractic services is different than the doctor’s obligation under state law to keep clinical documentation. Some insurance companies pay claims without requiring the submission of clinical documentation. However, the doctor risks disciplinary action by the chiropractic examining board, up to and including the loss of his/her license if he/she fails to keep the clinical documentation required by the state. The state requirements for documentation are minimums. Should a patient file a malpractice action against the doctor, the lack of detailed clinical documentation would hinder the doctor’s defense.

Are there any requirements as to how many chiropractors must be hired in a given county or geographic area?

The law says there must be s sufficient number of chiropractors to meet the needs of an insurance companies subscribers in a given market area. That does not mean that the most conveniently located chiropractor must be hired. The test of a “sufficient number” is primarily a subjective one. The insurance commissioner’s office will not usually get involved unless they receive a number of complaints from subscribers that do not feel that an area is underserved or that they must drive an unreasonable distance to receive chiropractic care.

What is the best way for a patient to get a rider removed from their insurance policy?

Riders are most common when an individual is applying for disability insurance, or a self employed person is applying for health insurance. In both of these instances, an insurance company is within their rights to put a rider on the policy that states that they will not pay for care of the spine.

The insurance company takes this position because the health information submitted by the patient indicates that they have had chiropractic care or a spinal injury sometime in the past. The insurance company assumes that if they have been injured once, the chance for a re-occurrence is more likely than if they had never been injured and they do not want the additional risk of providing coverage for the spine.

The first protection a patient has against a policy rider is to seek coverage from a different insurer. Underwriting policies vary greatly from one insurer to the next; it is possible that a less restrictive policy may be available if the patient is willing to shop around. Another strategy is to request that the insurer remove the rider if the patient does not have chiropractic treatment on the afflicted area for a period of time. For some insurers, this may be as little as a year while others will require a much longer treatment-free period.