Writing Effective Complaint Letters Tips to get results from TDI

by Shellie Pruden Director of Medical Practice Relations

Writing an effective complaint letter to the Texas Department of Insurance can be difficult. When you get frustrated enough to begin typing, sometimes it’s hard to know how to draft an effective correspondence. The following tips will help you draft a letter that will help get your desired results.

Keep it simple. Address only one issue per letter, so the TDI staff’s attention will not be distracted by a laundry list of complaints. Be clear what you are asking. The TDI staff should be able to highlight one or two sentences in your letter and know your expectation for resolving the issue. Include relevant examples that clearly support your complaint. If you are demonstrating a pattern and have 100 examples, it’s OK to send expanded documentation on five or 10. Offer to provide additional documentation when it’s needed, and be prepared to provide TDI all the relevant information you can. This may seem extreme, but it decreases the time it takes to come to a resolution.

Be careful of the tone. Keep the tone of your letter professional. Reflecting negative emotion in your complaint may feel good, but being pleasant and professional will serve you better. It always helps to thank the TDI staff for their work. After all, they, too, would like to see the issue resolved.

Complain to those who can make a difference. Filing a complaint with the TDI seems to be a last resort for many practices. However, the time to file complaints should follow a practice policy that includes a reasonable amount of
follow-up with the health plan and a reasonable timeline. TDI tracks far more than individual complaints; it also looks at trends, total volume of complaints, and timelines for resolution.

“An important part of insurance regulation is the review of complaints,” says Audrey Selden, TDI senior associate commissioner. “We welcome hearing from the provider community regarding insurance complaints.”

Over the past 3 years, the number of complaints has continued to decline significantly. TDI’s backlog of complaints is 20% of what it was when Ms Selden began her job 4 years ago.

Be careful whom you copy on the complaint. Although it has served Medicine well to keep legislators informed of ongoing issues with insurers, HIPAA privacy regulations apply to complaint correspondence. When sending copies to a legislator, make sure no patient identifying information is contained in the information you send.

You always can copy the TMA on your complaint. You can find a business partner agreement on the TMA Web site at www.texmed.org/pmt/etips/hfl_users.asp, along with the TMA Hassle Factor Log. TMA meets with all the insurance carriers twice a year, on behalf of its members, to discuss policies, specific issues, and trends. Once you sign the business partner agreement with TMA, you can copy them on specific issues that include privacy-protected information. Both TMA and TDI work diligently to resolve issues on behalf of physicians.

When you receive a reply from TDI, let them know if you are unhappy with the resolution. In the same professional tone, let them know what is missing. They often rely on information provided by the plan and need to know when additional intervention is required.

You can file complaints via the Web site, mail, or fax. TDI has a complaint resource tool for providers on its Web site at www.tdi.state.tx.us.

One of the most important tools in the complaint process is prevention. Make sure your practice is using updated CPT codes and is coding and filing correctly. The adage “garbage in, garbage out” holds true. The more accurate a practice is with patient information and filing claims, the better the chances of never having to ask the TDI for help.