Warning: DMOs May Kick You Out of Network for Complaining to HHS If You are Not Careful!

After we published our article last week about the HHS complaint line and its email address, we received a few emails from dentists. Several were excited about the possibility of complaining to HHS about their DMO troubles, but one had an interesting and dire warning.

Kicked out of network

The dentist wrote."I did this in the past and got kicked off the DMO. Their contract states that you must have gone through ALL of their hoops that they deem appropriate to achieve resolution or they have the right to boot you. Might want to check on that."

We did. While we don't have copies of the DMO contracts on hand at the minute, we sent the text of the above email to HHS and asked for a statement that we could publish.

HHS says ...

The following is what we received back from Jasmine Wiley, Children's Dental Program Specialist, Policy and Program Development, Texas HHS:

Medicaid managed care providers may file complaints with HHSC if they find they did not receive full due process from the respective managed care health plan.

Appeals, grievances, or dispute resolution is the responsibility of each MCO or DMO. Providers are encouraged to exhaust the complaints or grievance process with their MCO or DMO before filing a complaint with HHSC.

Once the MCO's or DMO's complaints or grievance process has been exhausted, complaint requests may be sent to HHSC.

Complaints about STAR, STAR+PLUS, STAR Kids, STAR Health, and DMO can be:

•Emailed to HHSC at HPM_Complaints@hhsc.state.tx.us.

•Mailed to HHSC at:

Health and Human Services Commission
MCCO Research and Resolution
PO Box 149030
MC: 0210
Austin, TX 78714-9030

Keep track and records of the complaint process

As DMOs can be retributive over such complaints, we want to make several suggestions here:

  1.  Don't make such complaints casually.  Gather all records and evidence in an organized manner.
  2.  Familiarize yourself with the complaint process(es) in the DMO contract(s). Find all the specific clauses that apply to complaints and their procedures.
  3.  Make sure you follow the procedure(s) and, for each step, document your actions on each one.  Your contacts with DMO representatives should be kept in written form eg. email or letter. That way there is a paper trail and evidence of following the procedure.  Do not accept phone calls or do not make phone calls unless you plan to record them. It is legal in Texas to record your telephone calls without informing the other party.
  4. Be methodical with following up the complaint procedures.  If a DMO rep doesn't get back to you in a timely manner, follow up with them.
  5. If the complaint process has been followed, make your complaint to HHS.  You will have all the evidence to hand.

 

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