April 18th, 2014 by Michele Trivedi
Help the IDOI Help YOU!
It is extremely important to file a complaint with the IDOI if you are experiencing trouble with health insurance coverage under the autism mandate in a commercial or ACA plan.
Examples of reasonable complaints:
- Provider not paid for months on end for legitimate claims and services
- Denial or large reduction in services without proper medical necessity review
- Denial of services based only on age
- Not approving care plans for over 30 days
- Insurer states no preauthorization for a service is required, then months after services have been provided states that preauthorization is required and that services will not be paid until after that process is completed
- Medical directors engaging in coercive or inappropriate behavior with clinicians during peer to peer calls or reviews, such as providing misleading information in order to coerce the physician to reduce therapy hours prescribed, threatening to send a case to review if the provider will not accept reduced BCBA supervision hours, yelling, hostile treatment, etc.
- Refusal by insurer to accept a diagnosis of autism that was done by a qualified medical professional
A complaint can be filed on the IDOI website, www.in.gov/idoi under “e-complaint”. You can also mail it to the IDOI at 311 West Washington St Suite 300 Indpls IN 64204-2787.
The IDOI responds to complaints, but if no complaints are submitted, they will not know there is a problem, so it is very important for families and providers to file reasonable complaints.
We greatly appreciate the IDOI’s on-going efforts to work with the autism community to ensure that people with autism are able to access the treatment that they are entitled to under our mandate, and now, the Affordable Care Act.
Examples of complaints that are not reasonable:
- Health insurance does NOT cover services provided under an IEP or ISP for the purposes of fulfilling state education requirements or Medicaid waiver services
- Health insurance does NOT cover respite care, transportation, and other services that are not medically necessary
- A school or parent cannot request ABA services in school and then ask the provider to “code the location” as outside of school in order to get insurance to pay for the service – that is fraud
- Complaints for coverage for interventions that are not accepted as evidenced based by the major medical societies, or that are provided by a practitioner that is not recognized by generally accepted medical practice and major medical societies or that does not have the accepted certifications and/or licensure required by law or by the insurer
These lists are not exhaustive, but represent some common issues we have seen.
If you contact the IDOI, and you are told they are “not taking autism complaints”, this is not true. Please document the person’s name and ask to speak to their supervisor and notify Michele Trivedi, The Arc Insurance Project Manager, at email@example.com. You can also contact Michele if you have a question about whether a complaint is appropriate to submit to the IDOI.