Kaiser Can't Be Trusted!

[insurehound]

I have a small group with Kaiser that recertified back in 2009. They were not in compliance as they didn't meet participation. So we figured out that we could do a carve out to make the Group whole.

So I spoke to several people at Kaiser to see what they needed. Me and the Group complied and submitted all of the paperwork requested. I then call Kaiser to confirm that they processed the recert/carve-out and the answer was "yes". BTW, I have notes of who I spoke with, what they said they needed and when they said it. This includes talking with the person who was in charge of processing the carve-out. She was nice enough to check while we were on the phone to see if they needed anything else. The answer was "no".

Come to find out that the carve out was never processed. I find this out after I call them the other day with a question. They recertified the Group and allowed them to renew but never processed the carve out.

Now I am being told that the reason the carve out was never processed is that there was missing information. The recertification dept. went ahead and approved the recertification and ASSUMED that the info would come later. Furthermore, the carve out never made it to the right person in their Small Group dept. who would have followed up on this with me.

The bottom line is that they are not approving the carve out and because of HCR, no new carve outs are being allowed. The Group will loose their coverage eventually. They are weasels. I provided everything they asked for. They had every chance to make this good but did not.

There will be hell to pay for this. Not sure if my Dept. of Insurance will help as this is an HMO but I must find a way to make this good. Unbelievable.

If I could move this Group I would but they don't have participation. Furthermore, Kaiser was the only carrier at the time that allowed carve outs without medical underwriting.

 

[leevena]

Don't take this wrong way, but the ultimate responsibility is not Kaiser's. It seems to me that you as their broker should have been aware of the rules/requirements and avoided the whole mess in the first place. Now go ahead and give it to me.

 

[insurehound]

If you ask the questions and get answers that don't include all of the info, then what else should you do? ESP? I only know the rules as they are explained to me which is why you have a Broker Services Team to call.

I'm sure you know everything.

 

[ABC]

I am not really familiar with carve outs. Is this a spousal carve out?

In your situation you did all the steps asked and followed up.

I would lay this on the carrier but if you don't have a relationship with a sales rep this might be tough.

You do not want to be the one to go to the DOI. Allow the client to do this. If you went to the DOI you might lose your contract with the carrier regardless to the out come.

 

[insurehound]

No, it's a management carve out which funny enough, is open again for use (with Kaiser) even with HCR.

Not sure the DOI handles this. I have to call them. HMOs are covered under another government agency but then again, this is not a medical claim issue.

They can have my contract. My relationship with my client is way more important. But goood point ABC.

 

[leevena]

It's not that I know everything, but close. MGT carve-outs can be an issue because of the potential for the group defrauding the carrier, adverse selection, and running afoul of discrimination regs. In CA, under your small group legislation, the carrier is given discretion as to whether they want to offer carve-outs or not. It is not a guarantee under AB 1672.

Let me explain my comment about broker responsibility. There is no doubt in my mind that carrier staff can make a mistake or that innocent miscommunications occur. Also, there is no doubt in my mind that brokers/employers will sometimes "bend" the truth to get the answer they want.

That being said, you are still the broker. Do you not present yourself as a source of information, help, etc.? If you do, how is it that you did not know the carve-out rules? Isn't that what you get paid for?

 

[DS4]

I've said this before, telephone calls, and, what some customer service rep tells me means nothing. Show me in writing. If I took everything a carrier CSR told me as the truth, I would be bankrupt and pennyless.
BTW, Kaiser falls under DMHC. Not DOI.

 

[insurehound]

Yes, I know what a carve out is and the rules. I know this by talking to the people in the various departments, reading underwriting and admin guidelines and learning from GAs. They met the rules. Kaiser is telling me that because I didn't write down two pieces of information that were not asked for that the recertification dept. still went ahead and approved the recert but assumed (there's that word that they used, not me) that more would come.

Then, the recert. never made it to the right dept. to be finalized. That's where I was told that one dept. never followed through with the other. If things had happened like they were suppose to, the problem would have been caught. So am I suppose to know their internal systems and procedures? They have absolutely no responsibility to call (like every other carrier does) to ask for more info? Or to tell me WHEN I CALL the recert. dept that more info was needed? Or to get the info to the right dept?

Do you sell Life Insurance? If you miss something on the app, does the company just sign off on it and forget about processing the paperwork or do they ask the agent for more info? When you enroll a new Group and miss something on the employer/employee app, does the carrier just say "Oh well" they didn't give us all the information to fit the "rules" so we'll pass. The agent should have known. Absurd.

I guess I need to go work at Kaiser and manually watch over every transaction.

BTW, I have found many underwriting and admin manuals to be out of date and incorrect. I have performed thousands of transactions via the phone with CSR's with no problems.

You guys and your egos...it's funny! I should have kept this to myself. My mistake. It's funny to see some of you try to make yourselves look better at the expense of others. Maybe we can see who can pee the furthest?

 

[Franz Kafka]

Why would they lose their coverage? Kaiser allows carve-outs. The group meant to carve out. So why can't they just process the paperwork now? (Just got an email that said Healthnet did small group carve outs now).

 

[Guest]

I've had problems with KP as well, but not with carve-outs.

I had excellent results working with the KP sales reps to get things fixed. You should contact your local Rep and explain to her (in the Sacramento area it is a woman) who I guarantee will help you get all of this rectified. Your rep may pass you off to someone in the Southern CA office, but that's OK.

The sales reps (local and in-house) know that if YOU are not happy that you are not going to bring more groups to KP. I doubt you will even have to hint at it. They "get it," at least in my experience they have.

I've found KP to be a very pro-active organization made up of dedicated and well-trained people and I'm sure you can get all of this taken care of rather quickly.

If not... contact Cindy Ehnes at the Dept. of Managed Health Care. I worked for her for about a year when she was in "acting" status and she is also very pro-active. She has a good staff, so start at the top. (Note: I heard that Cindy is stepping down even though she is a Democrat appointed by the previous Rep. gov. She is quite qualified and I'll bet she moves to a top job with some major carrier. She is a very capable CEO.)

You guys and your egos...it's funny! I should have kept this to myself. My mistake. It's funny to see some of you try to make yourselves look better at the expense of others. Maybe we can see who can pee the furthest?

As for the beating that you took here, I'm not sure what you were expecting but you got the same treatment that a lot of people get when they ask a question or bring a problem for resolution. After some 350 postings, I would think you would have known better. When it comes to getting accurate help and advice, vs. a stern lecture, "some days you get the bear and some days the bear gets you". . (I've always loved that scene with Riker and Picard.)

I am here... sometimes.