http://www.consumer.ftc.gov/media/video-0054-how-file-complaint
It seems like there are way too many scam artists trying to try and part you from your money.
Not many people realize that your health insurance policy is actually a CONTRACT… you agree to pay them so much every month and they agree to pay some per-cent of covered products/services in the contract.
Did you sign up for a particular Medicare Advantage Program or Part D program or some other health insurance company/policy because their promotional material/policy stated..
Was your decision influenced by the fact that the pharmacy that you normally patronized was in their “pharmacy network” ?
What if you can’t find a pharmacy in “their pharmacy network” that will fill your Rx.. or only find one.. supposedly in their network but won’t fill your Rx unless you pay a high price in CASH ?
If you see a healthcare professional outside of their approved network.. the contract/policy states that you will pay more… if you don’t pay your monthly premiums… they will stop providing you with covered products/services and cancel your policy/contract.
Pharmacy declines to fill your – legal/on time/medically necessary Rxs – for whatever reason.. they are being advertised in your policy as participating
You file a complaint with the insurance company and they decline/refuse to take action against the pharmacy for not adhering with the contract the pharmacy has with the insurance company.
Is this fraud/misleading/unfair business practices … which is the charge of the FTC to rectify such illegal acts ?
Filed under: General Problems
[…] Federal Trade Commission deals with consumer fraud […]
If any of us chronic pain sufferers have any knowledge of where to proceed when your grievance has been filed, but the insurance plan just refuses to investigate and after 5 months the grievance is still pending with no response please advise. I have files the grievances with CMS, but as stated in a previous post they are not required to respond to a Medicare grievance. My plan d booklet only shows the steps in each grievance process, but does bot say what happens if the plan refuses to respond to a grievance. If the grievance is denied you can go to the next process, but if it is still pending you can not advance to the next level so you are effectively prevented from getting your grievance determination. I guess all the plans have figured this out. CMS will take a grievance, but they try to get you to file it with your plan and even if they they do process a grievance they inform you when you ask then that you will not receive an answer to your grievance from CMS because they are not required to answer grievances. This is rediculous we need a real grievance process with teeth in the disciplinary stage.
I had a somewhat close situation which resulted in my being forced file a grievance with Health and Human Services. My mail order pharmacy had some problems filling my prescriptions in a timely fashion so naturally I complained to them and my insurance plan. Of course my verbal complaints had no effect so I filed grievances with the plan and the pharmacy. Again, I did not even get a response through 3 grievances with the plan and the pharmacy, so I filed the same grievances with CMS (Medicare) and I don’t know what happened at that point. As most of you Medicare recipients know CMS only responds to grievances when they need addition information so we never learn the outcome. Since nothing changed at my Medicare Plan d I decided to file a complaint with Agency for Health Care Administration and Health and Human Services and finally got some action. I received a letter from an investigator with the HHS enforcement division who went on to agree that the closed grievance process may not be adequate for the complaintant. She also agreed to keep my complaint open, but not active, so if I had other problems or I discovered people or facts which would show the pharmacy was continuing to delay my prescriptions she could just add to an existing file instead of start over. After her investigation of my facts she found enough evidence regarding one non-medical supervisor at the pharmacy failing to tell me the truth that she recommended the pharmacy discipline her and they terminated her employment according to this letter. I think this was purely to protect the pharmacy and promote the observation that the pharmacy was honest and would not tolerate their employees deliberately lying.
However, in the pharmacy profession that should always be the case total honesty. My points are that CMS complaints are useless, filing a grievance with your insurance plan is useless, and these procedures should be used when you plan on following the grievance procedure all the way. It is necessary to follow all the procedures or you cannot take the next step. It is not likely in my experience that your will receive resolution at this level. I believe that if we all begin to file complaints with HHS and AHCA maybe they will take action at least they respond and tell you what they are doing.