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SBD
Admiral
Joined: 19 Aug 2004
Posts: 1022
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 Posted: Sun Jul 23, 2006 11:00 pm Post subject: Need Your Help with my HMO!! |
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SBD
XXXXX ANY STREET
San Diego, CA 99999
(619)555-1212
SENT VIA FAX, EMAIL, AND CERTIFIED MAIL
July 20, 2006
California Department of Managed Health Care
Director Lucinda "Cindy" Ehnes
980 9th Street
Sacramento, CA 95814-2725
V: (888) HMO-2219
F: (916) 229-0465
RE: DMHC# 307243 – STD01
Subject: IMMEDIATE INDEPENDENT MEDICAL REVIEW
Dear Director Ehnes:
I am writing to inform of a gross mistake that has occurred involving your department. I understand that you are probably inundated with issues and would like to thank you ahead of time for taking a moment to right a wrong perpetrated on a 34 year old who was recently diagnosed with Kidney Cancer.
SBD requests an immediate IMR as entitled under California Law.
The purpose of this letter is to help DMHC see the truth about my previous request for an Independent Medical Review which your office apparently denied and converted into a grievance. Pacificare has denied coverage for an urgently needed procedure involving a re-operation for SBD’s kidney cancer. Since his in network oncologist
did not think it would have been prudent at all to wait any time, SBD should have been provided in network alternative in a timely manner as to not jeopardize his health further. The request was made on May 4, 2006 by both SBD and his Oncologist.
There was no written response received by SBD until he returned home after the surgery on May 19, 2006. If SBD had waited until he received the response from Pacificare, he would then have to wait to schedule the surgery for another unknown period of time which may have caused great harm to his health. It is unreasonable to force SBD to further jeopardize his life by unnecessary delays and misconduct from administrators at Pacificare.
SBD'S MEDICAL CONDITION
At the request of Dr. xxxxx, the original Urologist who performed the partial nephrectomy, Dr. xxxxx, Chairman of the Glickman Urological Institute, provided a second opinion. He reviewed SBD'’s CT Scan images and opinioned that a partial nephrectomy with an open procedure was the best option. Your records show that SBD suffers from Kidney Cancer involving a high Fuhrman grade (3 of 4) tumor. He had undergone a partial nephrectomy on March 31, 2006 which unfortunately had positive margins. The initial advice from his Urologist was to wait three months and repeat a scan. Given the severity of his cancer, IE having a Fuhrman Grade 3 of 4, this advice was not appropriate. This was also confirmed by Dr. xxxxx of UCSD who also stated the urgency of a re-operation to remove his kidney.
On May 1, 2006 Dr. XXXXX called SBD in response to a letter he received asking for his opinion and guidance with dealing with positive margins left after the unsuccessful partial nephrectomy. Dr. XXXXX also advised SBD that a re-operation was necessary and should be performed as soon as possible to remove any residual cancer. Dr. XXXXX has the required skills to perform this surgery and to determine any potential issues that might be found at the previous resection site. He was also familiar with SBD's condition since he provided the second opinion. The
surgery would have to use the previous incision site which would require great care to avoid additional complications. A date was set for May 12, 2006 for SBD to undergo a radical nephrectomy at Cleveland Clinic with Dr. XXXXX. SBD informed his Primary Physician, Dr. xxxx, on May 4, 2006. Pacificare should have informed SBD of
their denial immediately and scheduled the surgery with an in-network Urologic Surgeon as quickly as possible, but no later than May 12, 2006 as each day further endangered SBD'S life.
Kidney Cancer is one of the most difficult cancers to treat. Surgery is the standard treatment for contained kidney cancer. Radiation and chemotherapy are not very effective in treating kidney cancer. On May 4, 2006 SBD sent an urgent appeal for an out of network surgery at Cleveland Clinic to Dr. xxxx, his PCP. That same
day, his Oncologist sent a letter to Dr xxxx which said “I do not think it would be prudent at all to wait any time.” The letter says his Oncologist agreed that SBD should be treated at the Cleveland Clinic. In a letter dated May 11, 2006 and post marked May 16, 2006, Pacificare denied coverage for the surgery at an out of network provider. They stated that it was NOT MEDICALLY NECESSARY because he could have the surgery performed by an in network doctor in his plan. The letter completely ignores the URGENCY of my Oncologist’s request and only provides the names of two in network surgeons. It does not provide a date for the surgery that could be performed prior to or near the already scheduled date of May 12, 2006. Thus, there is no reasonable medical basis for Pacificare to deny coverage. The treatment requested is medically necessary and certainly could be said to be emergent under these conditions.
RELEVANT STATUTES AND ISSUES
HSC § 1374.31
(b) The department shall expeditiously review requests and immediately notify the enrollee in writing as to whether the request for an independent medical review has been approved, in whole or in part, and, if not approved, the reasons therefore. The plan shall promptly issue a notification to the enrollee, after submitting all of the required material to the independent medical review organization that includes an annotated list of documents submitted and offer the enrollee the opportunity to request copies of those documents from the plan.
(I received a Grievance Form from DMHC with a sticky note that said the DMHC required further information and to please fill out the form. No mention of the IMR which I resent with these forms. Attached were several of the documents submitted with my original June 1, 2006 request.)
This is to inform DMHC of unfair, deceptive, untrue or misleading statements and/or omissions of material fact in records, reports and/or other submissions from Pacificare.
It is imperative that SBD is able to see these documents submitted by Pacificare, to be able to: 1) identify any false statements; 2) make corrections before any additional harm is caused to SBD by these false statements, and 3) permit DMHC to thoroughly investigate, correct and appropriately penalize the improper conduct.
SBD hereby requests that DMHC provide or require Pacificare to provide him with copies of materials submitted to DMHC by Pacificare used in the DMHC’s July 13. 2006 decision.
Health & Safety Code § 1368(b)
(5) The department shall send a written notice of the final disposition of the grievance, and the reasons therefore, to the subscriber within 30 calendar days of receipt of the request for review unless the director, in his or her discretion, determines that additional time is reasonably necessary to fully and fairly evaluate the relevant grievance.
In any case not eligible for the independent medical review system the department's
written notice shall include, at a minimum, the following:
(A) A summary of its findings and the reasons why the department found the plan to be, or not to be, in compliance with any applicable laws, regulations, or orders of the director.
(B) A discussion of the department's contact with any medical provider, or any other independent expert relied on by the department, along with a summary of the views and qualifications of that provider or expert.
(C) If the enrollee's grievance is sustained in whole or part, information about any corrective action taken.
(The closing letter sent to SBD by DMHC, is almost entirely conclusory, failing to satisfy the specificity requirements of HSC § 1368(b)(5), largely ignoring SBD’s allegations and uncritically accepting Pacificare’s blanket denials.)
HSC § 1396. Documents Filed Under This Chapter; Willful False Statements Prohibited.It is unlawful for any person willfully to make any untrue statement of material fact in any application, notice, amendment, report, or other submission filed with the commissioner under this chapter or the regulations adopted there under, or
willfully to omit to state in any application, notice, or report any material fact which is required to be stated therein.
HSC § 1386(b) The following acts or omissions constitute grounds for disciplinary action by the director:
(3) The plan does not provide basic health care services to its enrollees and subscribers as set forth in the evidence of coverage.
(This provision is implicated because the false statements have been used as a pretext for failing to provide the basic health care services to which SBD was entitled under the evidence of coverage.)
(6) The plan has violated any provision of this chapter, [or] any rule or regulation or any order issued by the director pursuant to this chapter.
(This provision was violated as a result of the violation of e.g.: HSC §§1396; 1386(b)(3), (7),( , (9), (12); 1374.30; 1374.33; 1374.34.)
(7) The plan has engaged in any conduct that constitutes fraud or dishonest dealing or unfair competition, as defined by Section 17200 of the Business and Professions Code.
( The plan has permitted any violation by an employee who is a holder of [a] license, which would constitute grounds for discipline against the license (BPC 2533. The board may suspend the license of any licensee if he or she has been guilty of unprofessional conduct. Unprofessional conduct shall include, but shall not be limited to, the following:
(e) Committing a dishonest or fraudulent act which is substantially related to the qualifications, functions, or duties of a licensee.)
(9) The plan has aided or abetted or permitted the commission of any illegal act.
(The false statements alleged above are illegal acts under Business and Professions Code §§17200 & 17500 et seq., Civil Code §§ 1770(5), (7), (14) & (16), and Penal Code § 550(b)(1)-(3), as well as the HSC §§ noted herein.)
(12) The plan or other person occupying a principal management or supervisory position in the plan, has committed any act involving dishonesty, fraud, or deceit, which act is substantially related to the qualifications, functions, or duties of a person engaged in business in accordance with this chapter.
(The false statements alleged above are dishonest, fraudulent and deceitful.)
§ 1374.34(b) A plan shall not engage in any conduct that has the effect of prolonging the Independent Medical Review Process.
(Any false statements provided by the plan will prolong the independent review process by necessitating review and corrections. The process can only be completed based on accurate and complete information.)
It is also a Felony for any HMO to make misleading statements or omissions in connection with a claim for payment or other benefit pursuant to an insurance
policy:
Penal Code §550.
(b) It is unlawful to:
(1) Present any statement in opposition to a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains any false or misleading information concerning any material fact.
(2) Make any statement that is intended to be presented to any insurer or any insurance claimant in connection with or opposition to, any claim or payment or other benefit pursuant to an insurance policy, knowing that the statement contains any false or misleading information concerning any material fact.
(3) Conceal, or knowingly fail to disclose the occurrence of, an event that affects any person's initial or continued right or entitlement to any insurance benefit or payment, or the amount of any benefit or payment to which the person is entitled.
(c) (3) Every person who violates paragraph (1), (2), (3), or (4) of subdivision (b) shall be punished by imprisonment in the state prison for two, three, or five years, or by a fine not exceeding fifty thousand dollars ($50,000), unless the value of the fraud exceeds fifty thousand dollars ($50,000), in which event the fine may notexceed double the value of the fraud, or by both that imprisonment and fine; or by imprisonment in a county jail not to exceed one year, or by a fine of not more than one thousand five hundred dollars ($1,500), or by both that imprisonment and fine.
IN CONCLUSION
There was never any May 8, 2006 decision to deny coverage made or sent to SBD by Sharp Community Medical Group. SBD was told that his Medical Group approved the procedure in Cleveland due to the urgency of the issue (Chance of Cancer Spreading) as opposed to finding an in network alternative that would have been timely. SBD’s
May 4, 2006 request clearly states that the matter is URGENT, that his Oncologist will write a letter if needed by his provider and that the Urologist will
substantiate the URGENT and MEDICAL NECESITY of not delaying at all,
this procedure.
Why is it that neither the DMHC nor Pacificare explain in the denial why my Oncologist's opinion is incorrect or being disregarded?
Does a doctor’s opinion no longer matter to the DMHC?
Did DMHC ever receive a copy of my Oncologist's letter dated May 4, 2006 establishing that the procedure should not be delayed and agreeing that Dr. xxxxx at the Cleveland Clinic should perform the surgery without further delay?
Why did the DMHC send me forms and erroneously state that I had requested them from your department?
Why did the DMHC place a sticky note on these forms requesting additional information to process my request?
Why did the DMHC fail to inform SBD of the denial of his IMR when requesting this additional information?
How did the DMHC determined on June 2, 2006, one day after receiving my request for a IMR that it should be denied?? Based on what information?
Who at the DMHC could possibly have received all of the information necessary to deny an IMR in less than 1 day?
As the Director of the DMHC, I am sure you will want the answer to these questions as well!!
Thank you for your support.
Sincerely,
SBD |
Letter from my Oncologist to my Primary Care Physician regarding surgery at the Cleveland Clinic
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CANCER CENTER ONCOLOGY MEDICAL GROUP
Dr. XXXXX, MD
May 4, 2006
XXXX XXXXX, D.O.
5565 Grossmont Center Drive
La Mesa, CA 91942
RE:SBD
Dear xxxxx,
We had the pleasure of seeing SBD in the office.
As you know, he had a Lifescan done which showed a right kidney tumor. He ultimately had a right partial nephrectomy and unfortunately had positive surgical margins. The initial advise from his Urologist was to wait three months and repeat a scan, however he was anxious in that regard.
I told him that I felt he should definately be re-operated on as soon as possible. He has already made arrangements to go back to Cleveland Clinic to be operated on there, and I agree with that. I do not think it would be prudent at all to wait any time.
Thank you very much for allowing me to participate in his care.
Sincerely,
xxxx, MD
JOC/bdm/kah |
The Departnment of Managed Health Care has a web page for comments and feedback. If any of you have a moment, please send DMHC a note asking they grant my Independant Medical Review. If you can, send it also to your Senator's and Congressman. You can just copy this post, or rig
Thanks,
SBD |
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SBD
Admiral
Joined: 19 Aug 2004
Posts: 1022
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| Posted: Sun Jul 23, 2006 11:18 pm Post subject: |
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This is how they tricked me into filing a Grievance instead of moving forward with the Independant Medical Review. I faxed them the IMR request on June 1. A few days later, I get the letter below which is dated June 2, the very next day. The letter says that I requested the documents, but that is not true. I did not notice it right away because of the well utilized "sticky note". From that sticky note, I assumed I was giving them more information to further my IMR. It turned out that these forms are to file a Greivance. Doesn't this look deceitful and fraudulent!!
SBD |
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dusty
Admiral
Joined: 27 Aug 2004
Posts: 1264
Location: East Texas
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| Posted: Mon Jul 24, 2006 5:08 am Post subject: |
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Damn it SBD, when a person is going through the trauma of dealing with having been diagnosed with serious cancer they certainly don't need to be having to deal with this level of incompetence from their care provider.
Boy oh boy!
I sure hope you get them straightened out. If anyone can, I think you would be the one. Stay on em bro, looks to me like they are compounding one mistake with more mistakes.
Praying for your speedy recovery and cancer free future.
Dusty
_________________
Left and Wrong are the opposite of Right!
Last edited by dusty on Mon Jul 24, 2006 2:08 pm; edited 1 time in total |
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BuffaloJack
Master Chief Petty Officer of the Navy
Joined: 10 Aug 2004
Posts: 1637
Location: Buffalo, New York
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| Posted: Mon Jul 24, 2006 11:07 am Post subject: |
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SBD,
Have you written to or called your state's "Insurance Review Board"?
I don't know if Calif. has the same structure as New York (they're both super liberal so it's likely), but if the insurance review board receives a formal complaint from an insured person, they are supposed to review the grievance and champion them against the insurance machine. In NYS, insurance companies cannot get ANY rate hikes unless ALL pending notices by the board are cleared from the docket no matter how trivial they are. More often than not they will cave and pay off even if they think they are right, because delaying a rate hike costs them more. The best thing is that the board is not allowed to have any insurance people on it, just normal citizens. I was clued to do this by my sister, who worked for an HMO at the time.
I had a problem about 14 years back when my oldest daughter was injured on school property. My insurance and the schools insurance both had clauses stating they would pay any differences after the other insurance paid the claim. It wound up that neither would pay first and about a year into the standoff, the hospitals, doctors and other service providers all wanted their money from me. I filed a complaint with the IRB (with copies to both insurance companies) and I had duplicate checks from both insurance companies before the IRB even had time to react. I cashed them and sent half back to each of them.
In California, it may have a name other than the IRB, but if you check I'm sure there will be some avenue of relief for you to pursue. These people are basically little known by the public and serve as oversight to the insurance companies' perpetual quest for more money.
Good Luck,
Jack
_________________
Swift Boats - Qui Nhon (12/69-4/70), Cat Lo (4/70-5/70), Vung Tau (5/70-12/71) |
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SBD
Admiral
Joined: 19 Aug 2004
Posts: 1022
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| Posted: Mon Jul 24, 2006 2:28 pm Post subject: |
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That's the worst part of this whole thing. The Department of Managed Health Care is supposed to help HMO victims get help and redress their complaints. Instead, they pretended to be a patient advocate while actively doing the bidding of the HMO.
SBD |
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BuffaloJack
Master Chief Petty Officer of the Navy
Joined: 10 Aug 2004
Posts: 1637
Location: Buffalo, New York
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| Posted: Mon Jul 24, 2006 3:51 pm Post subject: |
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You have my sympathy SBD. I guess California is screwed up even more than New York (and that's hard to believe). It sounds like the HMOs have the patient advocates on the payroll.
Jack
_________________
Swift Boats - Qui Nhon (12/69-4/70), Cat Lo (4/70-5/70), Vung Tau (5/70-12/71) |
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Deuce
Senior Chief Petty Officer
Joined: 19 Mar 2005
Posts: 589
Location: FL
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| Posted: Mon Jul 24, 2006 6:14 pm Post subject: |
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SBD,
first my condolences, and I hope you can find justice in Calif, and on to a healthy, speedy recovery. My reason for the reply is to note wherein the problem lies with these State HMO Review Boards:
for example, in FLA:
http://www.sptimes.com/News/032301/news_pf/State/Florida_s_HMO_appeals.shtml
"Florida created the panel in 1985, making it one of the first of 40 states that now have them. It employs eight full-time staffers who help research and organize medical records and has a budget of $1.07-million, which comes from fees paid by HMOs. "
another 'follow the money' bureaucracy proving, like the dog, the hand that feeds them is the one that gets best served! So unless Calif has fixed their review board process, it's still paid by the HMO's and beholden to them....Check for another avenue for patient appeals if you don't get satisfaction from the review board, in Calif's huge bureaucracy there's bound to be one (or more).
G'luck
Deuce |
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SBD
Admiral
Joined: 19 Aug 2004
Posts: 1022
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| Posted: Thu Jul 27, 2006 8:39 am Post subject: |
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I sent my letter to Assemblywoman Shirley Horton's Assembly District 78 office. They were already reviewing the matter, but had not updated me on their progress. When I sent them the above letter, they called me right away and said they were going to call the DMHC to get some answers.
A few minutes later, someone from the DMHC called me and wanted me to send him copies including the sticky note. Today, I was called by another DMHC worker and wanted a copy of my new request for an IMR.
We shall see what happens next.
SBD |
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