Should privacy laws prevent us from advocating this case?

By | December 24th, 2016

When Phil Newman’s son cracked his tooth at camp last summer, a local dentist treated him for a root canal and affixed a cap. Newman assumed the treatment would be covered under his dental insurance with Cigna.

Wrong.

Newman has asked us to help him receive reimbursement for the cost of his son’s treatment. But we’re not sure we can, and it has nothing to do with our powers of persuasion.

Medical and dental treatment is covered under the Health Insurance Portability and Accountability Act (HIPAA), which contains a number of provisions that are supposed to safeguard the privacy of “Protected Health Information” (PHI), such as Newman’s son’s dental treatment.

The dentist who treated Newman’s son required a $800 payment in advance, which Newman made promptly. He then filed a claim on his dental policy for reimbursement of the payment. He estimated that Cigna would cover 80 percent, or $640, of the claim.

Because of the emergency nature of the treatment, Cigna denied the claim, stating that it was a medical claim rather than dental. It asked that the claim be refiled and coded as a medical claim. But the dentist’s office personnel don’t know how to submit medical claims to Cigna, which refuses to share the proper coding with the dentist’s office so that Newman can file a medical claim.

Newman spent hours on the phone with Cigna trying to resolve the issue, but Cigna won’t budge from its decision to deny his claim. He then turned to our advocacy team for assistance. (Contact information for Cigna can be found on our website.)

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HIPAA applies to Cigna, a “health insurance issuer,” as a covered entity. According to Subpart E, section 164.502(a) of HIPAA, “A covered entity … may not use or disclose protected health information.” But it “is permitted to use or disclose protected health information … to the individual, for treatment, payment, or health care operations, as permitted by and in compliance with section 164.506.”

With regard to minors such as Newman’s son, section 164.502(3)(i) provides that

If under applicable law a parent, guardian, or other person acting in loco parentis has authority to act on behalf of an individual who is an unemancipated minor in making decisions related to health care, a covered entity must treat such person as a personal representative under this subchapter, with respect to protected health information relevant to such personal representation …


Cigna’s Notice of Privacy Practices indicates that it may disclose PHI for the following purposes:

Treatment: – To share with

  • Health care professionals and personnel at health care facilities so they can determine your plan of care.
  • To help you obtain services and treatment you may need. …

Payment:

  • To obtain payment of premiums for your coverage.
  • To make coverage determinations – for example, to speak to a health care professional about payment for services provided to you. …
  • To obtain payment from a third party that may be responsible for payment, such as a family member.
  • To otherwise determine and fulfill our responsibility to provide your health benefits – for example, to administer claims.

Health care operations:

  • To support another health plan, insurer, or health care professional who has a relationship with you for activities such as case management, care coordination and quality improvement activities. For example, we may share your claims information with your doctor if you have a medical need that requires attention. We may also disclose your PHI without your written authorization for other purposes, as permitted or required by law. This includes: › Disclosures to others involved in your health care.
  • If you are present or otherwise available to direct us to do so, we may disclose your PHI to others – for example, a family member, a close friend, or your caregiver.
  • If you are in an emergency situation, are not present, or are incapacitated, we will use our professional judgment to decide whether disclosing your PHI to others is in your best interests. If we do disclose your PHI in a situation where you are unavailable, we would disclose only information that is directly relevant to the person’s involvement with your treatment or for payment related to your treatment. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location or your general medical condition.

Presumably, Newman could give written authorization to Cigna to discuss his son’s PHI with us. But we aren’t certain, given Cigna’s stonewalling on this claim, that we’ll be able to help resolve Newman’s case.

Should we pursue Phil Newman’s claim with Cigna?

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