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Linda Collins Blogger

“We're Not Gonna Take It Anymore”

Posted by Linda Collins | September 21, 2012

In the crazy world of reimbursement, linking Twisted Sister to an insurance lawsuit shouldn’t strike anyone as unusual.

Last week a group representing Los Angeles doctors and two patients partnered to sue Health Net Inc. for denying claims based on the insurer's definition of "medical necessity." The lawsuit, filed in Los Angeles Superior Court, accuses Health Net of unfair and unlawful business practices. While Health Net has not responded to the specific allegations in the lawsuit, it issued a press release noting that medical care is complex and there are differing medical opinions as to what constitutes medically necessary care

Does this mean that providers and patients have had enough and are fighting back? Should treating physicians define “medical necessity”? While a single lawsuit doesn’t constitute a trend, this one puts the medical necessity issue squarely in front of the California court system. Notably, the attorneys representing plaintiffs previously sued Health Net for rescinding insurance policies after insureds contracted expensive medical conditions, a suit that resulted in expensive fines against Health Net and new insurance rules.

Importantly, patients facing an insurance denial do have avenues of appeal, first internally with their health plan and then often with government regulators.

You can provide valuable clinical resources to support the appeal. Be familiar with the plan’s appeal process and follow the guidelines and time frames. Do not stop at the first level of appeal as that is what the managed care company wants from you. Instead, fight all the way to the external review. (If it’s a self-insured plan, your final level of review will be with the employer, not an external review agency.) If your state has a Consumer Assistance Program (CAP) utilize this source for assistance. For a listing of states with CAPs follow this link :

As the song says:

“oh We're Not Gonna Take It

no, We Ain't Gonna Take It

oh We're Not Gonna Take It Anymore

no Way!”


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