What are patient complaints?
Private insurance is regulated at the state level by the Department/Division of Insurance (DOI), which is also tasked with collecting and resolving patient complaints. Patients may file complaints about any insurance policy or plan sold by an insurance company. Complaints can be submitted about a variety of types of insurance, including auto, home, business and health.
For health insurance, the DOI is responsible for “fully insured” plans and plans sold on the state marketplace. In states that operate their own state-based marketplaces, a complaint may also be filed with the state marketplace. The DOI does not have jurisdiction over Medicaid, Medicare, Tricare, or other Federal plans, or over employer plans that are “self-insured.” Problems with health coverage provided by the state Medicaid program can be filed with the state’s Medicaid office.
Before filing a complaint, the patient typically must file an internal appeal directly with their insurance company challenging the insurance claim that has been denied. Unfortunately, the internal appeals process is complex, and individuals may need support from an expert, such as a health advocate, who is familiar with the process. Luckily, health insurance appeals are often decided in patients’ favor.
If no help is available in their state and the patient feels unable to file an appeal themselves, the patient should proceed with filing a complaint. This will ensure that state regulators are made aware of the issue they are experiencing with their health coverage.Why focus on patient complaints?
Why focus on patient complaints?
Patients often experience problems with their health insurance coverage that harm their health. Many are unfairly denied the coverage they are entitled to under their insurance contract or under state or federal law, including the Essential Health Benefit standards.
For example, if a patient receives a surprise medical bill from an out-of-network provider who treated her/him at an in-network hospital, the patient could file a complaint challenging the bill.
In another scenario, an insurer could refuse to cover residential substance use disorders treatment, asserting that the treatment was not medically necessary. A consumer complaint about this problem could assert that the consumer is entitled to covered treatments determined by her/his provider to be medically necessary. If similar medical/surgical services are typically covered, the complaint may also question whether this denial is a parity violation.
Complaints may be filed to document many types of health insurance problems. Feedback from consumers about their experiences helps identify limitations with health plans and build a case for systemic solutions.
Most patients are not aware that they have the right to file a complaint about their insurance. According to a Consumers Union survey, 83 percent of Americans have never complained to a government agency about any issue (e.g. cable bill, credit report error, bank fee, health insurance). Additionally, 87 percent of respondents do not know which state agency/department is responsible for handling complaints relating to health insurance.
Some patients are part of marginalized demographic groups and may be doubly or triply disadvantaged when it comes to health equity related to race, ethnicity, sexual orientation or gender identity, disability, immigration status, primary language, behavioral health needs and/or income level. Reporting health insurance problems to state regulatory agencies is one way that vulnerable patients can stand up for themselves against discrimination, and patient health advocates can help ensure that all consumers have access to equitable health coverage.
In addition to helping individual patients solve their health insurance problems, patient complaints provide an opportunity to document experiences of patients in the aggregate, enabling data collection for future improvement. Regulatory agencies receiving a large number of complaints about a particular insurance carrier or claim denials related to a particular type of covered benefit (for example, behavioral health) may be able to use patient complaints data to change policies to ensure fair treatment for all patients.What can health stakeholders do?
What can health stakeholders do to help?
This toolkit was originally authored by Meredith Munn, with recent updates by Dusan Stojicic and India Hayes Larrier in April 2023.
For questions, please contact Mona Shah, Senior Director of Policy and Strategy.