When escalating concerns to regulators, it is helpful to show trends and multiple data points. This page is a space for you to get some tips about how to engage with regulators and share your complaint experiences so that attorneys and policy specialists can aggregate data to provide better services and better advocacy.
Health Insurance Regulation Resources
When coverage stuff goes south, providers (and their patients/clients) have a few options to try to fix the problem.
- Contact the company and ask for reconsideration
- File an appeal on behalf of the patient/client
- Escalate concerns to the regulator by filing a complaint
- Get a lawyer and go to court
When do you reach out to your regulator?
If you believe that a company is wrongfully denying claims that should be covered, you should notify a regulator so that the company can be held accountable, especially when that company is repeatedly denying claims or cutting hours when the coverage clearly indicates that the services provided should be covered. Complaints typically must be tied to a specific patient, so make sure to reference in each complaint the concern that you have observed a pattern, and reference related complaints.
You can submit a complaint to a regulator at any point; however, submitting a complaint to the regulator after the insurer responds to a first-level appeal can show that you made a good faith effort to resolve the issue directly with the insurer. Typically, one question a service representative will ask when a complaint is filed is, “have you talked to the company?”
How do you figure out which regulator to contact?
Your patient/client may have a card that has the name and logo of a known insurance company, but that may not be the most helpful piece of information on that card. The type of coverage your patient/client has will dictate which regulator you complain to.
|
Coverage type |
Look for |
Regulatory Agency |
|
Medicaid/CHIP |
MEDICAID Agency name |
State Medicaid agency (e.g., Dept. of Human Services) Centers for Medicare and Medicaid Services |
|
CHAMPVA |
|
Dept of Veterans Affairs |
|
Medicare |
MEDICARE |
Centers for Medicare and Medicaid Services |
|
Employer-based, self-funded |
Administered |
Department of Labor |
|
Employer-based, fully-insured |
Only the insurance company |
State Insurance Regulator (where the insurance is issued) Department of Labor |
|
Individual insurance |
State Insurance Regulator |
How do you reach out to your state regulator?
Regulatory agencies will have a process for submitting complaints that is posted on the regulator’s website. Most require a written complaint to be submitted, and they typically accept email, fax, mail, and complaints submitted through a portal.
Find your state's DOI complaint form on the Autism Health Insurance Info Map.
How do you reach out to a federal regulator (DOL)?
Find the EBSA regional office for your state/region. There are 13 regional offices across the U.S. You can find the contact information for your regional office here.
Why is it important to submit a complaint?
Regulators often use complaints to prioritize their enforcement efforts and resource use. Multiple providers submitting multiple complaints from multiple consumers about a single insurer will raise flags for the regulators.
What will they do with your information?
When a regulator receives a complaint from a provider or consumer, service representatives will record the complaint in a database and follow-up with the company. When the company responds, the service representative will respond to the complainant (you or the consumer) with the company’s side of the story.
If a company provides an excuse or different interpretation of the facts, the service representative may close the case without resolving the issue. It is important when receiving the company’s response to make sure it answers the issues you raised in your complaint.
What will the ALRC do with your information?
The ALRC will keep your information confidential and in a secure location. Complaints submitted to regulatory agencies are not available to the public and there is no way to hold regulators accountable. By also submitting your regulator complaint to the ALRC you allow us to monitor what is happening on the ground, spot trends, and take action.
Coming soon!
What happens next?
While you may not see a trend with a single company within your practice, sharing your complaints experiences with ALRC will allow the attorneys and policy specialists to aggregate data that will help to make offer suggestions for lobbying, comment on state and federal legislative and regulatory priorities, and generally push for more effective oversight and enforcement.