By Dagmar Growe, LMT

“The Washington state Office of the Insurance Commissioner protects insurance consumers and oversees the insurance industry. We make sure insurance companies follow the rules and people get the coverage they've paid for.” (from the OIC website).

WSMTA has in the past recommended that practitioners encourage clients to file complaints with the OIC for a couple of reasons. We have as an organization worked with the OIC to advocate on behalf of our patients. This article is going into more detail on when and how to file a complaint.

It is important to understand that the aim of the OIC is consumer protection. They are not interested in contractual disagreements between providers (LMTs) and insurance companies, unless it affects patients directly. It is also important to note that the OIC deals with a huge number of complaints and is chronically understaffed. So, unless there is an easy resolution or a lot of squeaky wheels, complaints will likely not generate much of a response.

Payments denied: Complaints are easy to file through the OIC website but need to be filed by the patient, not the provider. Since many patients have a difficult time understanding why the claim has been denied I may provide a written explanation to the patient and authorize them to quote it or attach it to their complaint. The standard process for these types of complaints seems to be to forward them to the insurance company with a request to comment. Claims will either be paid upon review, or a more detailed denial can be the basis for further appeals.

Patients unable to obtain treatment: LMTs frequently receive calls from frustrated patients who are trying to find a provider who is accepting their insurance and has appointments available soon. When we cannot accommodate these patients, it is important to redirect their frustration. This is a question of network adequacy and could be one way to have a possible effect on inadequate insurance payments. If enough patients file a complaint, (the squeaky wheel), with the OIC about being unable to obtain services that are part of their insurance benefits, we hope that in time the OIC will address the issue with the particular insurer. If the insurer cannot provide an adequate network because LMTs are not willing to sign contracts at certain rates, insurers would be forced to increase rates to increase their network. This is not a quick fix, but at this point we know that the OIC is aware of the issue of inflated provider directories, and we suspect that recent rate increases may be connected to complaints about insufficient networks.

Here is a sample letter for these patients which you can adapt to your business:

Dear …

Thank you for contacting our office. We would love to work with you but unfortunately, (pick one of the issues below),

— we are no longer contracted providers with your insurance company. The low reimbursement rates we were receiving in exchange for offering high quality care were unsustainable for our business. 

— we are unable to accept new patients because the low reimbursement rates we receive for insurance work make it impossible to find and hire enough licensed massage therapists.

We encourage you to consult your insurance company’s provider directory to find available appointments at another office. We also suggest that you document the number of calls you have to make and the responses you get. Should you be unable to obtain care within a reasonable timeframe, we further suggest that you file a complaint with your insurance company and with the Office of the Insurance Commissioner (OIC). Complaints with the OIC are easy to file and here is a link to the OIC’s website https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status

We hope that you will find the care you deserve.

Sincerely