After Pacificare refused to pay for the second surgery, I sent a request for an Independent Medical Review of that decision since the surgery needed to be performed right away and Pacificare denied it the day before it was scheduled. The DMHC tricked me into filing a grievance.
This is how they tricked me into filing a Grievance instead of moving forward with the Independent Medical Review. I faxed them the IMR request on June 1. A few days later, I get the letter below which is dated June 2, the very next day. The letter says that I requested the documents, but that is not true. I did not notice it right away because of the well utilized "sticky note". From that sticky note, I assumed I was giving them more information to further my IMR. It turned out that these forms are to file a Grievance.
The DMHC decided for Pacificare because the surgery was not pre-authorized.
I decided to give the DMHC another try, this time for the cancellation issue. Their letter dated October 13, 2006 said that I would receive a decision within 30 days. As of today, nothing. I called them and they said someone would get back to me with an update.
Subsequently, an interesting revelation was announced regarding the DMHC and UnitedHealth/Pacificare. It appears that during the merger, their was a "conflict of interest".
State moves to fire HMO regulator The Schwarzenegger administration is moving to fire a top HMO regulator who held stock in UnitedHealth Group Inc. when he helped review the 2005 acquisition of PacifiCare Health Systems Inc.
Randolph said the department planned to more closely examine its employees' economic interest reports as well as institute a beefed-up in-house ethics training program.
SBD