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Boosted by glyph ("Glyph"):
joshua@emarhavil.com ("Joshua Wise") wrote:

Get fucked, insurance company. Here’s your reminder that, if you’re a California resident, and your health insurance refuses to cover something, it takes all of 5 minutes to file an independent medical review with the state, and statistically, 73% of the time the state will make your insurer pay.

That’s an insane amount! That is a lot of people getting screwed over, and that’s only the people who reported it who got compensation! And there are people who work for the state who take extreme joy in taking administrative action and fining insurance companies – so far this year, California insurance companies have already been fined $19.7 million, and those are not ‘medical loss’ numbers that count towards the amount of profit they’re allowed to make.

So do those people at the state a solid. You don’t have to be a green Nintendo plumber to make insurers pay; you can make a difference from your desk. If your insurance company causes you trouble, spend the five minutes to file with the DMHC helpline.

This year, my insurance plan just decided not to cover a normal preventative lipid and A1C panel for my annual physical, leaving me with a $200 bill from Palo Alto Medical Foundation. The state decided my insurance should pay it after all, and it’ll go into the file to see if they have a pattern of doing this. Blue Shield, get fucked.

Dear Joshua Wise: Thank you for sending your Independent Medical Review (IMR)/Complaint Form to the Department of Managed Health Care (Department). The Department reviewed your complaint in which you requested Blue Shield of California provide claims reprocessing and health plan coverage at the preventive benefit level for services received on March 24, 2026, with Palo Alto Medical Foundation. You explained that the laboratory tests completed on this date of service were related to a preventive annual visit and should be fully covered; however, you received billing statement(s) with a balance due. You expressed your concern with a possible coding and/or claims processing error and requested further review of this matter. Our review included your complaint documents, health plan response, and Evidence of Coverage (EOC or health plan contract).
Your request related to laboratory tests, codes 83036 and 80061, has been approved. The Department confirmed with Blue Shield of California that the associated claim(s) for these servcies will be sent for reprocessing at the preventive benefit level. Please allow 30 days for Blue Shield of California to process your approval and call the number on the back of your health plan identification card if you do not receive a revised explanation of benefits or continue to be billed for these specific services after that time.
Additional Information The Department finds that Blue Shield of California did not comply with your health plan contract and/or applicable California health plan law about the issue(s) in your complaint. Specifically, Blue Shield of California failed to correctly adjust your claim. Your complaint will be referred for possible review, investigation, or evaluation.