Did You Pay Up Front to Get Stabbed in the Back?
Like most people, you have likely been paying your health insurance premiums for a very long time. It can be extremely frustrating to find out that your health insurance company is now refusing to take care of you and your medical needs. If you have been denied medical treatment or service, now is the time to take action. You need an attorney who is not afraid to jump into the fray, fighting big insurance companies like Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente, Aetna, and United Healthcare.
Scott Glovsky is that attorney—Scott goes after insurance company big shots who value their lifestyle more than your life and your health. Scott is happiest when he is fighting injustice, particularly injustice perpetrated by big corporations that think they are untouchable. Scott will fight for justice for you because he truly cares about you, your story, your health, and your future. Scott’s hard-fought case victories have impacted millions of policyholders by forcing insurance companies to change their behavior—including their process of reviewing requests for medically necessary treatments.
About Kaiser Permanente
Kaiser Permanente Health Plan opened to the public in 1945, founded by physician Sidney R. Garfield, and industrialist, Henry J. Kaiser. Unions viewed Kaiser’s prepaid care plan as labor-friendly and affordable. The Kaiser Permanente nurses signed what might have been the first nurse’s labor agreement in the United States with hospitals in Oakland and Richmond, California. The Permanente Medical Group formed in 1948, with seven physicians—a key step in the evolution of the physician-led model.
Kaiser established health plans in regions in Southern California and Hawaii, continuing to expand its diverse pool of highly skilled caregivers, and in 1953, the name Kaiser Permanente was officially adopted. Kaiser continued to develop and grow, and in 1999, a Kaiser Permanente study conducted with the CDC was the first—and one of the largest—studies to identify the link between adverse childhood experiences and health over a lifetime. The study found that children who experienced significant levels of abuse, neglect, and family dysfunction were more likely to develop chronic health conditions later in life.
By 2020, with a pandemic and stay-at-home orders in place, Kaiser’s telehealth visits reached all-time highs. Within weeks, virtual care visits skyrocketed, from 15 percent to 80 percent, with more than 30,000 per day. Kaiser’s mail-order pharmacy dispensary also increased to its highest percentage and volume in history—3.6 million prescriptions in April 2020. Kaiser’s solid technological infrastructure allowed the company to rise to the occasion, ensuring patient safety and patient access during these difficult times.
Kaiser Permanente remains one of the nation’s largest not-for-profit health plans, with 12.4 million members. Physicians are responsible for medical decisions at Kaiser, and the medical groups that provide care for members are continuously being developed and refined with a goal of providing care in the most effective, efficient manner possible.
Kaiser has had its share of challenges. In August 2021, the Department of Justice joined together with whistleblowers in a suit alleging Kaiser’s Medicare Advantage plans overcharged the government by making patients appear sicker than they were to receive “risk adjustment” dollars. In August 2022 Kaiser mental healthcare workers went on strike requesting improved working conditions and additional staff to better serve patients. The Northern California Kaiser strike lasted for ten weeks. And in October 2023, Kaiser agreed to pay a $200 million settlement to the state of California because patients waited 19 days for a follow up mental health appointment instead of the legally allowed 10 day maximum.
With the ballooning cost of medical care, health insurance is an absolute necessity for individuals and families. Unfortunately, large insurance providers deny health insurance claims all too often, which can threaten a person’s health, livelihood, or impact their family.
It can be incredibly frustrating and scary to have a health insurance claim denied. Furthermore, the process of appealing a denial or filing a lawsuit against an insurance provider can be complex. If you have had a health insurance claim denied by Kaiser Permanente, a Los Angeles Kaiser Permanente health insurance denial lawyer can be an invaluable resource in helping you appeal a decision or file a lawsuit to recover for your damages and losses.
Why are Health Claims Denied by Kaiser Permanente?
Health care expenses have been cited as one of the leading causes of bankruptcy in the United States. In many cases, this can be directly correlated to a health care insurance claim being denied. Kaiser Permanente and other health management organizations often deny health insurance claims for the following reasons:
- A service or procedure is not covered under the claimant’s policy
- A procedure is considered experimental, cosmetic, or is intended for investigation
- The procedure required a pre-authorization that was not provided
- The services and/or healthcare provider selected is out-of-network
- Administrative or typographical errors
- There is insufficient evidence of a medical necessity
Health insurance providers have a legal obligation to handle all health insurance claims in good faith. According to Gruenberg v. Aetna Insurance Co. (1973), if a health insurer such as Kaiser Permanente “fails to deal fairly and in good faith with its insured by refusing, without proper cause, to compensate its insured for a loss covered by the policy, such conduct may give rise to a cause of action in tort for breach of an implied covenant of good faith and fair dealing.”
When a person’s health insurance claim is denied, it could mean that they do not receive the medical care that they need. Alternatively, an insurance company may deny a claim after a service is already rendered, leaving the policyholder to struggle with massive bills. No matter why your coverage for a treatment, service, drug, or procedure is denied, Kaiser Permanente is required to provide a written explanation for the denial, including how the denial can be appealed.
An experienced Kaiser Permanente health insurance denial lawyer like Scott Glovsky can help you appeal your denial of coverage, whether it involves an outright denial of a service, treatment, or drug, or a refusal to reimburse treatment you have already received. When you have a highly skilled health insurance denial attorney on your side, it is much easier to ensure enforcement of your insurance policy.
What Should You Do if Your Kaiser Permanente Health Insurance Claim is Denied?
When Kaiser Permanente denies a health insurance claim, the claimant may appeal this decision. For information on fighting your denial, download our eBook. According to a report released by the United States Government Accountability Office, a majority of claims that are appealed are reversed in the consumer’s favor.
Appealing a health insurance denial requires understanding the complexities of medical insurance laws and the California Insurance Code, as well as how to navigate through Kaiser Permanente’s confusing appeals process. An experienced Los Angeles Kaiser Permanente health insurance denial lawyer can help guide individuals and their families through this complicated process and work to ensure their appeal is given the attention it deserves.
According to Kaiser’s website, if you are denied coverage for a medical service or payment of a claim, you have the right to appeal that decision through a first-level appeal process, with an optional second-level review available (unless your contract states otherwise). If an appeal is not resolved to your satisfaction, you may be eligible for an independent review by a plan-specified entity or a state-certified independent review organization. Kaiser Permanente will pay for this review; however, you must abide by the decision rendered by the independent review organization. For this reason, it is important to get a Kaiser Permanente health insurance denial lawyer, like Scott Glovsky and his team, early.
Medicare and federal plan members must follow the independent review process administered by the individual programs. To begin your initial appeal, you or your attorney will complete the Member Appeal Request form and return it to the Member Appeals department. If a delay in your appeal could seriously impact your health, either you or your physician could request an expedited review process, which provides a determination on the appeal within 72 hours. If your denial document states the payment is the provider’s responsibility, rather than yours, then your provider must submit the reconsideration request—you may not appeal on behalf of your provider.
If you believe your health insurance claim was unfairly handled by Kaiser Permanente, contact a Los Angeles Kaiser Permanente health insurance denial lawyer today. A seasoned attorney can help you and your family work to hold this large insurance provider to their word and potentially secure the benefits you deserve. Call today to schedule a consultation.
FAQs Regarding Kaiser Permanent Coverage Denials
If you have been denied healthcare coverage by Kaiser Permanente, you may have many questions, including:
What if I failed to obtain prior authorization?
Your denial from Kaiser Permanente could be the result of your failure to obtain prior authorization or approval prior to obtaining a service or treatment. If the service you obtained was necessary for your health, your attorney may be able to help you receive payment or reimbursement for the treatment or service through the appeal process or through a lawsuit, when appropriate.
What if I don’t understand why my claim was denied?
You should have received an Explanation of Benefits that clearly states the reason for your claim denial. The Explanation of Benefits may state that the condition for which you have requested treatment or services is related to a pre-existing condition, that you chose a provider that was out-of-network, that you have surpassed the lifetime benefit cap for the condition for which you are being treated, that your treatment is considered experimental, or that your treatment has been deemed “not medically necessary.” The most effective way to overturn a claim denial will depend on the reason for the denial. You may need to prove medical necessity, show the treatment was not related to a pre-existing condition, provide a valid reason for using an out-of-network provider, or show why the experimental treatment is essential to your health or not in fact experimental at all.
Can I get help when filing a Kaiser Permanente appeal?
While your healthcare team can support your appeal, the best course of action may be to contact an experienced attorney who can prepare and file your claim appeal. When you have an attorney who understands the entire process, it is much more likely your appeal will be successful.
Kaiser Permanente News
In 2018, Kaiser Permanente was fined $100,000 for its failure to provide appeal information for denied insurance claims to insured individuals. Although Kaiser agreed to correct its actions, a complaint filed by an enrollee sparked a review of the practices of Kaiser Permanente, and multiple violations were found. When examiners reviewed Kaiser’s files between 2016 and 2017, they found that 175 out of 180 letters sent to insured individuals failed to inform the individuals they had only five days to submit additional information for their appeals. Further, the vast majority of complaints received from insured individuals were about authorization disputes and denials.
- Kaiser Settles Our Autism Class Action for Denying Applied Behavioral Analysis and Speech Therapy – Agrees to Reimburse Families up to $9.29 Million
- Kaiser Permanente’s Mental Health Workers Strike
- Class Action Lawsuit against Kaiser for denying ASD treatment
- Kaiser Denies Life-Saving Treatment to our Client Jalal Afshar
- USC Hospital Sues Kaiser over Nonpayment of Bill – Scott Glovsky quoted in the LA Times
How Scott Glovsky Can Help if You’ve Had a Coverage Denial
Like most people, you probably expect your insurance to cover you when you become ill or need a treatment or service. It can be extremely discouraging to receive a denial for a treatment or service your doctor has ordered—and that you need. Attorney Scott Glovsky has been taking on big insurance companies for two decades, helping people just like you in the process. Scott Glovsky got Kaiser Permanente to stop systematically denying Applied Behavioral Analysis and speech therapy to children with autism spectrum disorders. This decision impacted 45,000 kids with Kaiser insurance, providing a $9,290,000 settlement for class members and autism research. In this case, Scott was a finalist for the 2014 Consumer Attorney of the Year Award from the Consumer Attorneys of California. Scott also got Kaiser to provide more than 100,000 California members living with severe mental illness access to medically necessary residential treatment in a court-approved class action settlement.
As you can see from the above, Scott Glovsky is the health insurance denial lawyer you need in your corner when it is time to fight a big insurance company. Scott can file your appeal with the internal processes of Kaiser Permanente, create a case before the state’s review board, or take your case to court to enforce a policy. If Kaiser Permanente denied your health insurance claim, you need Scott Glovsky in your corner. Contact the Law Offices of Scott Glovsky today to find out how we can help you during this difficult time. We want to make sure you receive the treatment you need while ensuring Kaiser Permanente provides the coverage you were promised.