State Insurance Commissioner agrees with Kaiser's payment denial for 14 medevac flights

Fourteen insured islanders will be burdened with bills of about $23,000 for medevac flights. The state Insurance Commission's investigator, who was not a physician, determined that Kaiser Permanente's  denial of payment for 14 medevac flights from the San Juan Islands was correct. The Office of the Insurance Commissioner (OIC) informed the county that they will not take any more action on the county's complaint and the decision is final.

At the June 19, 2019 San Juan County Board of Health meeting, county Health and Community Services Director Mark Tompkins said. "There was a bit of good news." He explained that originally there were 41 flights [between September 2018-March 2019], payment of 24 of those were denied.  OIC said six of the 24 should be paid. Another four had some kind of mistake . That reduced the number of denials to 14. The OIC did not say on what grounds the 14 were determined to not fit the criteria.

Kaiser Permanente purchased Group Health and is currently the only insurance carrier for the Affordable Care Act policies in San Juan County. 

Dr. David Grossman, senior associate Medical Director, Market Strategy & Public Policy Washington Permanente Medical Group wrote a letter to Board of Health Chair Dr. Dale Heisinger stating: "Following our meeting in April, our team once again reviewed our coverage and clinical review practices. I can confirm that they are compliant with Washington state laws and the provisions within Kaiser Permanente Washington's filed member coverage agreements. Physicians independently perform appropriate utilization management reviews using objective clinical criteria. All Kaiser Permanente Washington members are covered for emergency transport without preauthorization to the nearest appropriate facility (including air ambulance)."

Tompkins noted the denials had increased from about 10-12 percent to 58 percent. He told the BOH that he was disappointed that the increased percentage was not addressed in the OIC's report.  "They didn't dig into that much," Tompkins said. He did say the OIC agreed to convene the physician to physician meeting which had been discussed previously. 

"Kaiser is leaving January 1. Lifewise may come in. OIC said they will vet them and see, whether they vet anyone we will see," BOH member Dr. Geyman. "The precedent is established that  non-physicians probably, clerks even maybe, can deny shipping out anyone by air...This problem is not fixed at all. We should do a rebuttal letter  to what I think was a total unsatisfactory investigation by OIC. I think that it looks to me that they are kinda pretty close to, even in bed, with any carrier."

BOH Chair Dr. Dale Heisinger said, "I wasn't aware this was the final report. Thought we would be able to give our responses." 

"I don't think it is bad to write a letter to OIC and put in the letter that we expect they convene the physician to physician meeting out here,"Tompkins said. "Our community needs to understand and our physicians need to know the criteria...If we have to operate under these rules it will change how we provide medical care." 

[Editor's note: The two medevac carriers - www.islandairambulance.com and www.uwmedicine.org/airliftnw/aircare - offer memberships. Please note that these are not insurance policies. They will cover your out-of-pocket costs that are left after your insurer pays. If your insurer does not pay, the memberships do not kick in.  Both companies will help with appeals.


Dear Dr. Dale Heisinger,

I recently received your letter, thank you for reaching out. My apologies for delay in responding, as it went to my address for our research institute. Our team certainly understands the community's concerns and we found the time hearing directly from you last month was incredibly valuable. We are committed to the health of all the communities we serve, and we too want to ensure that residents have access to emergency care.

Following our meeting in April, our team once again reviewed our coverage and clinical review practices. I can confirm that they are compliant with Washington state laws and the provisions within Kaiser Permanente Washington's filed member coverage agreements. Physicians independently perform appropriate utilization management reviews using objective clinical criteria.

All Kaiser Permanente Washington members are covered for emergency transport without preauthorization to the nearest appropriate facility (including air ambulance). I do appreciate the concerns that you and others have raised about the lack of sufficient access to urgent and emergent after-hours health care services for San Juan Island residents.

Sincerely,

David Grossman, MD

Senior Associate Medical Director, Market Strategy & Public Policy Washington Permanente Medical Group

 

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