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  • Joshua Wisejoshua@emarhavil.com
    Jul 9, 2026, 4:30 PM

    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.
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Replies

  • Joshua Wisejoshua@emarhavil.com
    Jul 9, 2026, 4:48 PM

    Some of the instances of this are pretty good reading. In this case, Blue Shield decided not to cover a newborn and then stonewalled the parents – first over $218, and then up to like $2k or so worth of bills.

    The state fined them $100,000 for this single instance (and, of course, they paid out to the parents). You, also, can make administrative malpractice like this unprofitable! It’s your civic duty to help the State close the budget gap, at your insurer’s expense!

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  • Andrew Drakeadrake@sfba.social
    Jul 9, 2026, 5:15 PM

    @joshua that's a good tip, thank you!

    While this probably would not work at the moment, back in 2021 IIRC I had a box of COVID tests where there wasn't enough extraction buffer for one of the tests in the kit. Lacking a convenient way to contact the manufacturer, and given that the total value was like $6, I spent 5 minutes filing a defective medical device report with the FDA, and didn't really expect anything else to happen.

    A couple weeks later I got a *phone call* from the test manufacturer apologizing for the defective test, and a promise that a new box of tests was in the mail (which showed up soon after).

    Amazing what a regulator who cares can do when you give them something to work with!

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  • Joshua Wisejoshua@emarhavil.com
    Jul 9, 2026, 5:18 PM
    @adrake I mean, on the one hand, blah blah it's just extraction buffer on a diagnostic test blah blah, and I am a little more sympathetic to that manufacturer than to an insurer.

    On the other hand, if their OQC program didn't detect that, are there other things that their OQC program didn't detect on other, more important, things they're making...?
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  • Andrew Drakeadrake@sfba.social
    Jul 9, 2026, 5:41 PM

    @joshua I was already somewhat annoyed with them because they were packaging the buffer in a separate little blister pack that you had to tear open and transfer to the sample tube, a finicky and sometimes lossy process. No surplus in the packet, even if you didn't spill any and squeezed it as flat as you could, it would still often end up a hair shy of the line (though I didn't complain about those).

    But I figured if they were already willing to skimp on the cheap visible component, they were probably willing to skimp on the expensive invisible antibodies, and if their QC let the easy thing through it's not promising for the more critical parts. (Not to mention any other devices the manufacturer might make!)

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  • Joshua Wisejoshua@emarhavil.com
    Jul 9, 2026, 6:36 PM
    @jonathankoren @lindsey 'reversed' also counts. 'reversed' means 'the insurance company, when they realized they were going to have to provide documentation to the state, went "ah fuck nvm" and decided to cover it' (even though their previous internal appeals process had deemed that their final decision was that they weren't gonna cover it!! huh!!). so medical necessity is 53% + 23% = 76%
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  • Ruth [☕️ 👩🏻‍💻📚✍🏻🧵🪡🍵]platypus@glammr.us
    Jul 9, 2026, 6:40 PM

    @joshua It's a slightly different case, but my best friend is in CA and recently got $14,000 check from Kaiser for a settlement because they didn't properly cover mental health care that she absolutely needed. That is a wild amount to have paid out of pocket (over a few years) and she almost didn't believe it worked until the check cleared, but there was a whole class action thing and CA got her the money back.

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  • Joshua Wisejoshua@emarhavil.com
    Jul 9, 2026, 6:46 PM
    @platypus Oh yes, the billboards on the 101 for 'Kaiser: now, with access to therapy!' is like a huge regulatory success story. What they don't say on the billboard was '... because the DMHC fined us $50M and we undertook a consent decree to follow the law, and also pledge another $150M to other community behavioral health organizations!'. I guess that isn't as effective advertising copy
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  • DFX4509B (Joshua Mason)dfx4509b@friendica.world
    Jul 9, 2026, 6:49 PM
    @joshua I've said this before and I'll keep saying it, insurance is a legal protection racket. The only difference between an illegal protection racket and an insurance company, is the insurance company doesn't send hitmen after you if you lapse on your protection money, the illegal protection rackets do, or at least that's how they're typically depicted.
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  • Duckbilled Plattypus.pattykimura@beige.party
    Jul 9, 2026, 7:10 PM

    @joshua It's as if health insurance companies decided it is a cheaper/more affordable risk to pay life insurance premiums to replace one CEO than to reduce suffering and pay claims fairly to millions of paid subscribers. They are a bloodless lot.

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  • Strider Uwe 🇺🇦🇨🇦🇲🇽UweHalfHand@norcal.social
    Jul 9, 2026, 7:17 PM

    @joshua This is great info to have! My insurance co just started playing games with a prescription… it was small enough that I just bought it out of pocket, and later they approved it, but it’d be great to have this in my back pocket! Next time I will! Keep those bastards on the straight & narrow…

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  • Tim Yocumtky@hachyderm.io
    Jul 9, 2026, 9:52 PM

    @joshua congrats! Worth noting is that you do not need to be a California resident to invoke the IMR process — lots of remote workers with California companies and plans written out of CA are eligible.

    I got Anthem to pay up when they decided to stop covering long term RXs. Because all results are published (anonymized) it’s easy to see what other IMRs have yielded and decide how to proceed with data on your side.

    Ever since, when they deny random services I simply suggest that I’d be happy to do another IMR and it’s like a cheat code, denials become approvals.

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  • technicattechnicat@universeodon.com
    Jul 9, 2026, 10:14 PM

    @joshua I also had a good experience with the state of California on this years ago, I sent a letter complaining that healthnet dropped my coverage for non-payment after they cashed my check, and I sent the letter to the wrong agency, the one that handles HMOs, but they responded promptly with a letter that said they forwarded it to the correct agency and that one contacted the insurer who reinstated coverage with a letter saying it was my fault for illegibly writing the account number on the check that they cashed anyway (plus they managed to write the wrong name on that letter). I'm usually too lazy to follow up but this is a rare instance I sent a thank you letter to the person at the state agency. Btw, this was before ACA so there was almost no obligation for insurers to cover you, Blue Shield of CA rejected me for having high cholesterol, saying I was welcome to apply for their high-risk policy.

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  • quixotequixote@mastodon.nz
    Jul 9, 2026, 10:45 PM

    @joshua That 73% rate, bad as it is, implies the insurance cos are afraid of California.I remember reading somewhere (Charles Gaba?) that the national rate is closer to 80%.

    There is no way that 80% (or even 73%) of an insurance company's refusal to pay costs can be an accident, a mistake of some kind, an 'oopsie oh I missed that'.

    These aren't kindergartners randomly throwing paint at a wall and deciding based on that. These are people with some kind of medical background. They're harassed and underpaid and overworked. But even so, a 10% error rate would be huge.

    The fact that the decisions get reversed the minute they're afraid somebody might look over their shoulder and notice tells you that the companies are doing it intentionally. There's a name for that. Fraud.

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  • Sharpe!Rgsharpe@sfba.social
    Jul 9, 2026, 11:58 PM

    @joshua As a state worker who enjoys serving nearly 40 million stakeholders in my own small way, thank you for applauding DMHC's workers' work.

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  • 955_36955_36@sfba.social
    Jul 10, 2026, 12:17 AM

    @joshua Thanks for publicizing this. After trying to get a $3000 refund check issued from Blue Shield for over a year, DMHC got it issued and in my hands in less than a month.

    Currently working on another problem with Blue Shield where they cancelled our policy and replaced it with a more expensive one (> 10x the cost) because of a mixup a third party made in reporting our income. (CA Covered policy)

    I hate that we don't have Medicare for everyone. I can't wait until the end of the year when my wife will also move to Medicare and we don't have to deal with Blue Shield anymore.

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  • Joshua Wisejoshua@emarhavil.com
    Jul 10, 2026, 2:42 AM
    @955_36 There were days when I lived in the Bay where I dreamed about taking out a radio ad on Live105 publicizing that DMHC can solve problems like this
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  • PhangurlPhangurl@starbase80.wtf
    Jul 10, 2026, 2:45 AM

    @joshua Thank you. My insurance company is wrongfully refusing coverage. This is very helpful.

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  • Joe Pallasjpallas@hachyderm.io
    Jul 10, 2026, 5:04 AM

    @joshua I could be wrong, but I think PAMF may have a part in this. If they submit the claim for a lipid panel with a diagnosis code for hyperlipidemia, then suddenly it’s not preventative care, it’s monitoring a disease and not fully covered. I tried to get them to change the diagnosis code once, and they wouldn’t. But the insurance company is the one deciding that tracking my cholesterol level is not routine preventative care if I am already known to have high cholesterol.

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  • Joshua Wisejoshua@emarhavil.com
    Jul 10, 2026, 6:25 AM
    @jpallas I think so too. I had the same experience, that they said 'nah, we're not recoding anything', when I asked them first, but I also suspect this was in part their fault, though.

    My opinions about the Sutter Health monopoly in the Bay are, really, comparably vitriolic to my opinions on the insurers, if not more so. But, annoyingly, they have no regulators to respond to (and the State settled the antitrust case for far too little, IMO), so there's nothing to do about it, so I don't really post much about that kind of thing.
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