CLAIM REIMBURSEMENT REFUSAL BY YOUR CLIENT'S INSURANCE COMPANY
As you probably know, insurance companies are in the business of making money, and some of them will stop at nothing to limit or eliminate the services they must provide to their policyholders under the terms of their contracts. In fact, over the past decade, insurance companies have increasingly begun to deny reimbursement of benefits to their policyholders, to dissuade them from taking advantage of their coverage and ultimately increase their profits.
As insurance companies are governed by the insurance Act, they are required to adhere to the terms and conditions of the contractual guarantees of their policyholders. Furthermore, group insurance contracts are comprised of three distinct parties, namely the employer, the insured, and the insurance company. Consequently, when an insurance company declines to reimburse its insured, it is not a matter of concern to you, as only the parties to the insurance agreement possess the legal authority to intervene in this matter.
Furthermore, as there are no governmental guidelines governing the various methods of alternative medicine, an insurers decision to deny a claim based on the assertion that the provider or its professional organization fails to meet the criteria and requirements imposed by the insurer, this reason lacks a legal foundation.
Moreover, given that the information supplied on the CPMDQ insurance receipt is complete and that insurers can verify the status of a license from our website, there is no justification for an insurer to impose the requirement for you to include your address on your receipts or to require you to register on their platform to reimburse their policyholders claim.
Given this consideration, we recommend that you refrain from registering on insurance platforms or indicating your address on your receipts, as by voluntarily providing them with your contact details, you as well willingly give your consent for the insurance company to investigate on your competence by persistently questioning you through phone calls and spontaneous visits to your office unexpectedly.
As the CPMDQ places a significant emphasis on safeguarding personal data it has obtained from its members, it is expected that its members will also safeguard the information they have obtained from its clients and uphold their oath to article 7.01 of the CPMDQ code of ethics. Subsequently, as a condition of their oath, members are prohibited from disclosing any information from their clients’ files.
In 2014, the SSQ implemented a modification to its accreditation criteria for health care service providers in Canada. This modification required that the about 80 professional associations in the field of alternative medicine in Canada give the SSQ a complete list of their members, which includes their contact information, among other important information. If an association did not consent to this requirement, the SSQ would decline to reimburse claims from its members but to safeguard the personal information gathered on its members, the CPMDQ declined to comply with the insurers threats and filed a motion to the courts to intervene.
Although the Court ruled in favor of the CPMDQ, it sometimes happens that an insurer takes the liberty of not reimbursing the claims presented by its insureds, however, as the judge so clearly pointed out during the trial, if the insured contests the refusal of reimbursement through Small Claims court, he/she will assuredly have an excellent chance of winning. This could be the reason, since 2014, for many policyholders, the reimbursements have been granted immediately after they sent their formal notice, without the need for a legal battle. Insurance companies don’t want to be sued when their position is not legitimate, and their arguments are not convincing.
Considering the above-mentioned explanation, regardless of the alleged reason given by your client’s insurance company, it is imperative that you refrain from attempting to rectify the issue of claims that have been denied by your client’s insurance companies and that you instead, encourage them to peruse the contents of the page provided at the linked below.
CPMDQ INSURANCE RECEIPTS POLICY
L.R.Q. c., S-40
Are you authorized to issue insurance receipts as a member of the CPMDQ?
In the absence of regulations governing the various alternative medicine practices in Quebec, all active members in good standing are eligible to issue insurance receipts to their clients. Members who are inactive or on sick/maternity leave are not eligible.
Under what coverage am I eligible to issue receipts?
You can issue insurance receipts based on the titles for which you have been accredited through the CPMDQ. For example: Naturopath, Homeopath, Massage Therapist, Kinesitherapist, Orthotherapist and/or Osteopath and/or Kinesiologist.
Must I include taxes on my insurance receipts?
Under no circumstances should you include the taxes on your CPMDQ insurance receipt, as taxes are not reimbursed by the insurer, but rather by the government. The insurance receipt is a declaration of insurance, not a sales receipt.
What amount should I indicate on the insurance receipt?
The total amount paid by your client, before taxes.
Who may sign my insurance receipts?
Your receipts can be prepared by your assistant, however, to be accepted by insurance companies, they must be signed by the member. Also the entire treatment must be performed by the licensed member of the CPMDQ. You may not issue an insurance receipt for services rendered by a practitioner other than yourself.
What should I do if my client asks for a new receipt because the original was lost or damaged?
You may provide a new insurance receipt labeled “Duplicate”. To avoid double payment by the insurer, the details and dates on the duplicate receipt must be identical to the original receipt.
May I issue an insurance receipt for treatment provided to a family member?
Insurance companies’ guidelines prohibit the issuance of insurance receipts to immediate family members or anyone living in the same household. Immediate family” includes the spouse, children, father, mother, brothers, sisters, parents-in-law, grandparents, sons-in-law, daughters-in-law and grandchildren of the member and spouse.
Can I issue an insurance receipt for a gift certificate?
No, gift certificates are not reimbursed by insurance companies.