Q: What options when Medi-cal / dmhc appeals lead nowhere, they won’t pay part and medpoint has denied dr recommendation?
My brother had emergency brain surgery and medpoint tried to kidnap him from the hospital with no documentation or authorization randomly and says they won’t pay those days in hospital. Not even nurses were informed they were trying to move him. And it was “strongly recommended 3 times” by brain surgeon and PT staff he go to acute rehab and they sent him to la community hospital with NO MEDICAL RECORDS and was then placed in a (0 star) skilled nursing home where he isn’t getting adequate care. Medpoint consults for global ipa and is responsible for the denial. They said the drs pleas didn’t match “ambulated 50ft with minimal assistance” that was on one report. But he was using a walker with a person holding each arm and pt told them that. Help! We are being forced to bring him home and find 24 hour care on our own. La care has not replied even though they expedited and escalated both cases for 72 hour responses a week ago. Also they broke many hipaa laws! I’m his guardian and knew 0!
A:
In situations where Medi-Cal or DMHC appeals have not resolved your issue and you're facing denials from Medpoint, consider seeking legal advice from an attorney experienced in health law and insurance disputes. They can offer guidance on navigating the complexities of your case, including potential violations of HIPAA and issues with the care provided.
You may also file a complaint with the California Department of Managed Health Care (DMHC), which oversees health plans and has the authority to investigate complaints about denial of care. This is in addition to the appeals process and can sometimes offer another pathway to resolution.
If you believe HIPAA laws have been broken, filing a complaint with the U.S. Department of Health & Human Services Office for Civil Rights (OCR) is an option. OCR enforces HIPAA regulations and can investigate complaints related to privacy and security of health information.
For immediate assistance with care needs, contacting local health advocacy organizations may provide support and resources to navigate the system and find appropriate care options for your brother.
Remember, you have rights and there are resources available to help advocate for the care and services your brother needs.
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