What can a Member do when a client's claim is denied payment by their insurance company?
First and foremost, it is important to understand that in a group insurance policy, there are three distinct parties involved: the policyholder, also known as the employer, the insureds, also known as the employees, and the insurance company.
Therefore, when your client informs you that their insurer is refusing to reimburse payments for services you rendered, regardless of the reason the insurer is refusing to reimburse, there is absolutely nothing the health care provider (the member) or their professional association can do to force the client’s insurance company to comply with the terms of their contracts.
Thus, when this situation occurs, regardless of the reason or rationale for the insurer’s denial of reimbursement, any attempt by the service provider to communicate confidential client record information to the insurer is a violation of Section 7.01 of the Code of Ethics for Members. CPMDQ.
It is understood by the oath of the member in article 7.01. of the CPMDQ Code of Ethics, that the member must without exception respect the professional secrecy of any information obtained in the exercise of his practice. The member may only be released from his professional secrecy when ordered by the court. For this reason, a member of the CPMDQ is at no time authorized to disclose to anyone outside the CPMDQ, any information obtained by the member of the CPMDQ from a client.
Given that an insurance company can easily verify the status of a member via the (Insurance Company and Public) section of our website and that the member has all the information required on the receipt to reimburse the claim, the member is prohibited from contacting the client’s insurance company.
If an insurance company has questions regarding the information on the receipt, they can contact their client directly or, if they wish to confirm membership status, they can email us.
Thus, when this situation occurs, regardless of the reason or reason for the insurer’s denial of reimbursement, any attempt by the service provider to communicate confidential client file information to the insurer is a violation of Section 7.01 of the Member Code of Ethics. CPMDQ.
Finally, in response to the above question on what a member can do when an insurance company refuses to reimburse a claim, for the above reasons, they can only direct their clients to the web link below.
Insurer and General Public Section
“Rejection of a claim by an insurance company”
Highlights of the CPMDQ v. SSQ court case