Benefit & Risk Management Services, Inc.

BRMS is just the claims processor, we are not a carrierChecks were cut but held until BRMS received funds from the Plan Sponsor to cover the checksOur checks are good for one year therefore there was not a need to reissue the check when it was mailed on 4/24/The check has been voided and
the claim will be reprocessed for payment

This is a BRMS Self Funded Client for their dental benefitsClaim was received and processed, currently awaiting funding from the Employer GroupProvider was spoken to today 6.27.2017 and advised that the claim has been processed and once funded it will be mailedProvider was given the
check number and amount

I am rejecting this response because: These dates are misleading and I received conflicting information when speaking to their representative.

I am rejecting this response because: The decision regarding how long a check is valid is made by the bank accepting the check.  You cannot force an institution to accept a check that is 7 months old if their policy is not to accept any checks over 6 months. If I sent you a check to cover a service you provided for me, dated it 1/1/2014 and said "This check is good for 5 years" I have no doubt your financial institution would have a problem with this.  This is the same situation.  It is not your call to make.  Period.  Also, the processing of the claim does not concern me.  Do not try to pass off the blame to someone else.  The ONLY thing that concerns me is this check which was created by BRMS which is NO LONGER VALID at my institution (again, you cannot force them to change their policies).  This claim does NOT need to be reprocessed.  If YOU wrote the check, YOU need to rewrite it.

Review: Since September 24th, my doctor and I have provided the proper paperwork needed to process approval for necessary medication. I have acknowledgement from the [redacted] Management (pharmacy) provider that it was received and is waiting for Benefit & Risk Management Services (the plan administrator) to approve the medications since they have a limitation cap. October 19th I contacted [redacted] Management (provider) and was told that BRM has not approved anything. I emailed BRM on Oct 19th and received a reply to contact customer service. I contacted their customer service at BRM and was told blatantly that my doctor has to send the paperwork. He already did. I went to the doctor and got a copy of the paperwork processed and on Oct 21st I sent the authorization paperwork via email to BRM asking for a response. I received an acknowledgement of receipt from a medical management assistant telling me that the provider should be calling me. On Oct 26th I sent a follow up email asking why this hasn't been processed. Oct 27th I called their customer service and left my callback number. On Oct 28th I sent another email since they did not call me nor acknowledge my emails with a more concerned email. To date, nothing from BRMWell over a month of disappointment from BRM and causing issues with my quality of life. I have to reduce my normal abilities, cancel activities with my little league baseball team, having troubles sleeping, and overall challenges. My doctor approved the required medication and BRM wants to ignore it, delay it, or just refuse to acknowledge it. This is extremely disappointing, frustrating, and honestly embarrassing that I have to go through this issue and limit my lifestyle on account of BRM.Very Disappointed!Desired Settlement: I want BRM to acknowledge, apologize, and process whatever approval needed immediately. I want any and all limitations placed on my approved doctor medication needs to be lifted and allow for the needed prescription to be refilled ANYTIME. I also feel that the pains and challenges I have been put through should also be compensated by BRM by paying for all my specific medication for an entire year. This is not a lot to ask from a large corporation.

Business

Response:

We

empathize with Mr. [redacted] and the delay he experienced in receiving his

prescription refill. As the Third Party Administrator, BRMS has business

processes to follow in order to provide prescription authorizations. Below, is

a summary outlining the events which caused the postponement of the

authorization.BRMS

received a request for prescription refill on September 24, 2015 from Dr.

[redacted]. Unfortunately, we did not receive the updated clinical notes and signed

script for the medication in order to conduct and complete the appropriate

review for medical necessity and requested the appropriate documentation.However,

after review of the prior clinical notes from 2014 and the prescription Rx

Medication History Report, on October 19th, 2015, BRMS authorized a

30 day refill without expiration with the instructions to [redacted] that

further refills past this 30 day will need to be reviewed for medical necessity

which includes current clinical notes and signed script. Unfortunately, According to our records, it

appears, [redacted] Management mistakenly informed Mr. [redacted] that he only had

one day to refill his medication.On

October 21st, 215, we received an email from Mr. [redacted] with part of

the information required to complete a medical necessity review for

prescription medications. Since we were

still missing the clinical information, a call was placed to Dr. [redacted]’s

office to get updated clinical notes and a signed script for the requested Rx

Medication.On

October 26th, 2015, BRMS received the necessary documentation from Dr.

[redacted]’s office.On

October 28th, 2016, BRMS authorized refills from 9/23/2015 –

4/30/2016 for Mr. [redacted]’s medication and informed [redacted] Management of

the authorization so they could update their system to allow refills up to

4/30/2016.BRMS strives to

provide excellent customer service for both our clients and their members.

Based on the outline above, we hope that you understand that we have done all

that we could to help resolve this issue as quickly as possible according to

the business processes we have to follow.

Consumer

Response:

I am rejecting this response because: These dates are misleading and I received conflicting information when speaking to their representative.

Review: From May of 2012 through January 2013 I received treatment at a Dr. that was covered by BRMSs carrier [redacted]. BRMS paid some claims at first, became very slow in processing claims and 5-6 months into treatment stated they would not cover any of my care racking up my medical bills to $70k+. BRMS has found every reason not to pay my claims due to my diagnosis even when their carrier [redacted] pays for this care on a routine basis for other patients. BRMSs business is to help the businesses they provide insurance to and they do NOT care about the impact their decisions and delays have on patients. They are in the business to deny any large care outside of going to the Dr. a few times/year for routine care. In addition my husband required a surgical removal of cysts and they are denying those because they tested benign after removal. Their website claims that they offer "medical management or case management" and they blamed me that my "case" never went through medical management when that is their internal process. They also claim to process claims within 6 days on their website and in some cases it took them 2-3 months to even review paperwork that was submitted by my doctor. When the patient's doctors state their is medical necessity, BRMS does not side with the doctors and it is the doctors that are supposed to decide this as well.Desired Settlement: I would like BRMS to pay my claims since they were negligent in sending my case to their medical management department, they were negligent in a proper response time for claims. During my appeal, they did not respond to my requests for documents and they are in direct violation of ERISA on multiple occasions. If I do not receive a proper response or settlement of my medical claims with my Dr. being paid I will take BRMS to the CA board of insurance as well as litigation, if necessary.

Business

Response:

As a Third Party Administrator, Benefit & Risk Management Services (BRMS) has processes and controls in place to ensure that the medical services are provided and managed in accordance to the Employer’s Benefit Plan. As this is a self funded plan, we are bound to ERISA’s guidelines. The first few claims sent by Dr. [redacted] were office visits which were paid as per the benefit plan. A few weeks later Dr. Jedaldi sent in several claims for IV vitamin infusions treatments which are not a covered service under the plan. After reviewing all the case notes, and to fulfill Ms. [redacted] and Dr [redacted]’s appeal rights, the documentation was sent to three (3) independents organizations to conduct peer reviews on separate occasions. All peer review organizations determined the treatments to be inconsistent with standard of care guidelines and therefore the claims are denied. Under the ERISA and ACA regulations for non grandfathered plans, Independent Review is binding. There is the further option, if the expert does not approve the treatment or services and the member does not accept the decision reached, the issue becomes a dispute. Settlement of disputes is the responsibility of the client (Employer). The client shall make all final decisions with respect to disputed claim payments. As previously stated, BRMS has to abide by the Employer’s Benefit Plan and ERISA Guidelines. We are not at liberty to make decisions outside of the plan. We do have internal processes and controls in place to make sure our clients and their members receive the right care in accordance to their benefit plan. Below is a detailed timeline to explain the events which lead to the determination and what process was followed: 5/16/13: Dr’s office person ([redacted]) called BRMS customer service to request eligibility and benefits related to specialist care. It is noted that the claimant’s primary care provider referred the claimant for pain management evaluation. 9/25/13: Provider called customer service inquiring why their claim for IV infusion of vitamins was denied on 7/17/13. It was explained that this service is not covered under the claimant’s health care plan. Provider requested a copy of covered benefits and also a copy of limitations and exclusions. This was sent via fax to Dr [redacted]’s office person [redacted]. 10/11/13: Customer service received a 2nd call from the provider asking whether or not treatment of the claimant required pre certification. No specifics were provided so a Managed Care referral form for services was faxed to the provider’s office. Dr [redacted]’s office person noted they had sent all their medical records for this claimant had been sent to CIGNA. It was explained that if any care required retrospective review BRMS Managed Care would provide the necessary review. 11/5/13: Additional claims from Dr [redacted] were denied due to lack of pre certification including further IV infusions of vitamins which had previously been denied as a non covered service under the claimant’s health benefit plan. 12/13/13: Customer service received a call from [redacted] disputing the need for pre certification of services. There wasn’t any rational provided as to why the provider was disputing this. Again a Medical Management referral form was provided. Customer service also referred this case to Managed Care due to ongoing treatment without pre certification. Medical records previously provided to CIGNA were also provided to Managed Care for review. 12/17/13: BRMS RN/Certified Case Manager reviewed the medical records provided. These records were not complete. Dr [redacted]’s office was called to discuss the course of care provided and also additional medical records. BRMS RN/CCM spoke directly with Dr. [redacted]. BRMS RN/CCM also made contact with the claimant explaining her role, reason for calling, noted participation in case management was voluntary and provided her direct contact information. The claimant provided a positive response and agreed to participate in the Managed Care process. Rational for the RN/CCM intervention was clearly stated, that there was a dispute arising related to the care provided to the claimant. The claimant was aware of the issues as Dr [redacted] had notified the claimant and also noted he would no longer treat her until the care issues were resolved and his claims were paid in full. Dr [redacted] had all medical records faxed to BRMS Managed Care. 12/17/14 to 12/23/14: Review of medical records and services provided. 5/13/13 to 10/22/13. The total amount of services provided without certification was $72,000.00. Additionally we found that the actual treatment by Dr [redacted] was initiated 5/13/13. Treatment of the claimant was stopped on 10/22/13 due to non payment of claims. 12/23/13: RN/CCM review of medical records completed. The treatment of the claimant was found excessive, IV vitamin infusions were found to be excluded under the Employee’s Health Benefit Plan and inconsistent with evidence based medical guidelines. The services provided could not be certified at the RN/CCM review level. Dr [redacted] & the claimant were both notified via phone calls of the determination. It was explained that the case would be presented at the next Claims Review Committee meeting and it was anticipated that the case would be referred to peer review. 1/9/14: The case was brought to Claims Review Committee meeting. After review of the facts , it was recommended that the case be referred to Peer review via an Independent Review Organization (IRO). Since Dr [redacted]’s specialty is Physiatry (pain management specialist) the independent reviewer must be of the same specialty. ERISA regulation (§ 2560.503-1(b) and (c)). Written notification was provided to Dr [redacted] and the claimant of the determination, ERISA regulation (§ 2560.503-1(f)(2) and (4)) 1/13/14: Determination provided in writing by the Independent Reviewer. “The treatment plan described by Dr. [redacted] is not consistent with the standard of care. The standard of care for treatment of chronic pain syndrome and fibromyalgia calls for active independent rehabilitation and possibly with pharmacological assistance from antidepressants, Cymbalta, or the tricyclic antidepressant Elavil. Passive treatment with trigger point injections, nerve blocks, or intravenous infusion of multivitamins is not consistent with this standard of care.” 1/15/14: Independent review determination faxed and receipt of documents confirmed received by Dr [redacted]. The same determination was mailed via certified, signature required to the claimant. 1/21/14: [redacted] from Dr [redacted]’s office contacted BRMS Managed Care appealing the determination. Dr [redacted] requested a phone conference with the reviewer but would only be available Friday, 1/24/14 at 10am 1/22/14: Independent review entity notified of appeal, and Dr [redacted]’s request to speak with the review and Dr [redacted]’s availability. 1/24/14: 10am. The IRO reviewer contacted Dr [redacted]. After their 10 minute conversation the reviewer provided a written addendum. “SUMMARY OF CONVERSATION: I called the office of Dr. [redacted] at 408-402-3167 and spoke with Dr. [redacted] on 01/24/14 at 10:00 AM PT. We spoke for approximately 10 minutes. Dr. [redacted] discussed at length his impression in that trigger point injections, vitamin treatment, intravenous infusion of vitamins and nerve blocks indicating that these treatments are the standard of care for fibromyalgia. Dr. [redacted] reported that this patient has had profound functional improvement, and that the results supported the necessity of this treatment. Dr. [redacted] indicated that he would fax additional information to me with regard to the medical literature supporting an indication for this treatment. ASSESSMENT: I received some documentation from Dr. [redacted]. This documentation referenced to a broad survey of basic science and clinical investigational research in fibromyalgia. This documentation does not address the standard of care. Dr. [redacted] provided no additional office notes or results of testing.” 1/28/14: Updated determination faxed to Dr [redacted] and receipt confirmation to file. The same determination was mailed via certified, signature required to the claimant. 2/11/14: Received a written request from Dr [redacted] to have the independent reviewer send him the references utilized in making the determination to deny services. 2/17/14: E mail to the IRO requesting on behalf of Dr [redacted] all references used by the review specialist to make their final determination. 2/18/14: Received confirmation that the references requested by Dr [redacted] were sent to him on this date. 3/25/14: We received a written request from the claimant to provide her multiple documents. The claimant further notified BRMS that she was not satisfied with the determination. The Claims Review Committee was meeting on this date. The case and request by the claimant for information was presented. It was determined that many of the items requested were contracts between BRMS and the client. These documents are confidential and would not be made available. The claimant requested a copy of all medical records in our possession. We do not retain medical records. The remainder of the documents requested had already been sent to the claimant and receipt confirmed via certified mail receipt. Additionally the claimant was again appealing the determination. We contacted the HIPAA compliance officer for our client (Employer) and discussed the issues especially noting that the claimant was requesting further expert review. The client had already been involved and approved the initial submission to an expert for determination. The client was satisfied with the determination and the rational and acknowledged that they would not approve further expert review nor would they agree to payment of the disputed claims again based on the expert opinion. The determination was provided in writing to Dr [redacted] and the claimant. 4/21/14: [redacted] from Dr [redacted]’s office called stating that the reference material used by the reviewer had not been received by Dr [redacted]’s office. I noted that I have confirmation that the material was sent to them by the independent review entity 2/18/14 and they have a receipt that this information was received by Dr [redacted]’s office. I further noted that confirmation has been obtained that their office and the claimant has exhausted the appeals process per ERISA regulation (§ 2560.503-1(j)). The letters sent 3/25/14 were again sent to Dr [redacted] and the claimant. 5/21/14: BRMS received notification that the claimant had obtained legal representation. The claimant’s attorney noted that we had not sent the entire medical records to the independent reviewer, they are disputing the credentials of the independent reviewer, Dr [redacted] has stated that the reviewer based his determination on the presumption that this was a Worker’s Compensation case and demanded all records associated with the adverse determination. The opinion of the reviewer’s credentials and the assumption that the reviewer review the case as work related is unsubstantiated. The reviewers credentials were impeccable, he is of the same specialty and nowhere in the documentation does the reviewer state this is work related. The claimant’s attorney furthermore demands a new independent review of the clinical records and any other information we may have. In response to the attorney it was noted that we requested all clinical/medical records from Dr [redacted] prior to the initial submission to the IRO. Dr [redacted] assured us that he had provided all the clinical documentation he had for the claimant and this is what we forwarded to the IRO. We do not retain medical/clinical records to do so would be a violation of HIPAA. We did although provide the attorney with all the documentation regarding the adverse determination including the IRO report, addendum and all letters and receipts. 8/4/14: The claimants attorney once again filed an appeal of the 1/13/14 adverse determination stating that in the claimants and providers opinions the reviewer was not qualified to perform the review and that furthermore the reviewers knowledge of the claimants primary diagnosis, Fibromyalgia was limited at best. We responded acknowledging the claimant and Dr [redacted]’s opinion and noted that at this point we would refer the case back to the Claims Committee and our client (Employer) in a good faith effort to resolve the adverse determination. 8/18/14: This case and the arguments, opinions and summary of recent medical/clinical records received and reviewed were again presented to the committee. The HIPAA compliance officer for our client was in attendance telephonically. The opinions provided by the attorney, provider and claimant are purely subjective. The credentials of the reviewer are not an issue. Last this case was not reviewed as a worker’s compensation case so the arguments and opinions do not appear to have any merit. Review of the recent medical/clinical records (~ 400+ pages) do contain additional information but in these records Dr [redacted] has provided documentation supporting the rational for the care provided. Given the additional information and in a good faith effort to resolve this case it was recommended that a 3rd level final external review with a different IRO be performed. The HIPAA compliance officer noted that their Self Insured plan is now non grandfathered as of 1/1/14. Under the ERISA and ACA regulations for non grandfathered plans Independent Review is binding. There is the further option that if the expert does not approve the treatment or services and the member does not accept the decision reached the issue becomes a dispute and settlement of disputes is the responsibility of the client. The client shall make all final decisions with respect to disputed claim payments. 9/4/14: The client provided that they approved a 3rd level external review based on the appeal submitted on behalf of the claimant for an external review. The client noted that since their plan is no longer grandfathered this final determination that will be submitted to another IRO (under ERISA regulations when the dispute related to medical care the external independent review will be binding) will be binding. The client will only agree to payment of the disputed claims if this last review finds the care to be medically necessary. 9/18/14: Claimants attorney notified of the clients determination. All clinical/medical records that the attorney has assured us is the complete file was prepped for submission to an external IRO. It is anticipated that the determination should be returned by 10/9/14. 10/7/14: Claimant’s attorney provided additional documentation he wanted included in the review process. The IRO was notified to interrupt the review process as there was additional documentation received that we have been asked to include in the reviewable documents. The Director of Managed Care who was managing the review process was out of the office. 10/20/14: The Director reviewed the additional documentation sent. There wasn’t any evidence that these were duplicated records and were immediately forwarded to the IRO. The claimant attorney was notified that at this point no further documents would be accepted. The IRO process will be completed with the additional information provided. 11/20/14: Final determination provided by IRO.” Based on the National Guideline Clearinghouse (NGC): The following nonpharmacologic treatments have shown little or no evidence in efficacy for Fibromyalgia treatment: Chiropractic therapy Massage therapy Electrotherapy Ultrasound Trigger point injections Flexibility exercise (Huynh, Yanni, & Morgan, 2008) While there are only three medications which are U.S. Food and Drug Administration (FDA) approved for Fibromyalgia treatment (duloxetine, pregabalin, and milnacipran), there are varying levels of evidence for the off-label use of many pharmacologic agents in FM management (Hauser et aI.,) 2009) Therefore based on the above key recommendations by NGC, ALL the treatments performed that included IV infusion of multivitamins, Trigger point injections, Ultrasound (US)-guided spinal ligament injections, osteopathic/chiropractic/massage manipulations, intercostal nerve blocks, US-guided ligament injections , etc are considered experimental/investigational and not medically necessary.” Medically Necessary means: 1. There is an Illness or Injury which requires Treatment; and 2. The confinement, service, or supply used to treat the Illness or Injury is: a. Required; b. Generally professionally accepted as the usual, customary, and effective means of treating the Illness or Injury in the United States; and c. Approved by regulatory authorities such as the Food & Drug Administration. Dr [redacted] submitted clinical care guidelines which he referred to as his treatment protocols in the care of claimant. The IRO noted that “the articles submitted only reinforced the determination that the treatment was experimental/investigational. The articles submitted along w/the clinical notes are all based on experimental care that is not considered consistent w/the majority of the medical community as standard of care practices.” 11/21/14: The IRO determination was faxed and emails confidentially the claimant’s attorney. The claimant was sent a copy of the final determination via certified mail received receipt required. 11/25/14: The claimant’s attorney is again appealing the determination in spite of receiving notification that the appeals process has been exhausted. BRMS strives to provide excellent customer service for both our clients and their members. Based on the outline above, we hope that you understand that we have done all that we could to help resolve this issue according to the business processes we have to follow.