Health plans terminate relationship with Vantage Medical Group The California Medical Association (CMA) has learned that two health plans, the Inland Empire Health Plan (IEHP) and Molina Healthcare, are terminating their contracts with Vantage Medical Group. Two other plans, Blue Shield of California and Care1st Health Plan, have issued notices of material breach with an intent to terminate. The plans have filed requests with the California Department of Managed Health Care (DMHC) to transfer their enrollees to other delegated groups. According to IEHP’s block transfer filing with DMHC, Vantage engaged in conduct that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP’s Medi-Cal managed care enrollees. According to IEHP, Vantage had, over a period of years, engaged in conduct that violates state and federal laws regarding the prompt and timely payment of provider claims, includes manipulating and falsifying claims, banking records and audit reports. The plan filings with DMHC indicate over 280,000 enrollees will be affected by the IEHP and Molina terminations as follows: Inland Empire Health Plan: Termination effective August 31, 2018, affecting 171,425 enrollees in Riverside County and 102,621 enrollees in San Bernardino County. Molina Healthcare: Termination effective August 31, 2018, affecting 7,413 enrollees. Blue Shield and Care1st issued notices of their intent to terminate, if Vantage fails to correct the breaches. If the breaches are not corrected to the payors’ satisfaction, another 6,000 enrollees will be affected as follows: Blue Shield of California: Termination effective August 31, 2018, affecting 2,979 enrollees. Care 1st Health Plan: Termination effective August 31, 2018, affecting 3,034 enrollees. CMA will provide additional information on the transitions as it becomes available. Physicians should be diligent in obtaining updated insurance information from patients and verifying eligibility at the time of scheduling, if possible, to avoid unnecessary patient confusion and denials of payment for services rendered. Patients may also be able to continue to see their physicians, even if they are not contracted with the patient’s new delegated entity, under California’s continuity of care law. Under continuity of care laws, patients with an acute condition, serious chronic condition, duration of a pregnancy, duration of a terminal illness, care of children between birth and 36 months, or for the performance of a surgery or other procedure that has been authorized, may qualify to request continuity of care. To request continuity of care, patients should call the health plan number on the back of their ID cards. For more information on continuity of care requirements, see CMA On-Call document #7051, “Contract Termination By Physicians and Continuity of Care Provisions.” CMA will provide more information on IEHP’s transition once we received updated information on the receiving groups. Practices that are experiencing problems with Vantage or issues resulting from the plan terminations are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org. July 11, 2018 General, Managed Care, Medi-Cal Blue Shield, Commercial Payors, Department of Managed Health Care, DMHC, Payor Contracting 0 0 Comment Read More »
CMA survey finds rampant health plan payment abuses Despite a California law passed in 2000 to address widespread payment abuses by health care service plans, many payors continue to flout the law. A recent survey by the California Medical Association (CMA) confirms that health plans regularly engage in unfair payment practices, with two-thirds of physician practices reporting routine payment abuses in violation of state law. The Department of Managed Health Care (DMHC) has been slow to address provider complaints and has taken few enforcement actions against health plans that unlawfully underpay providers. When DMHC has acted, the penalty amounts have been small in relation to the economic injury to consumers and providers. Because of this, some health care service plans make economic decisions to violate the law, knowing that any penalty amount that may be imposed will be outweighed by the extra revenue the health plans will generate by, for example, underpaying medical care. Last month, CMA, along with its county medical societies and several specialty societies, surveyed physicians to obtain feedback on the health plans that are routinely engaging in unfair payment patterns, the types of violations and the results of physician efforts to resolve the issues both through internal plan processes as well as through DMHC. In a period of nine days, 741 physician practices representing thousands of physicians responded to the survey. Key survey results include: Two-thirds of physician practice respondents report routine problems with plans engaging in various unfair payment patterns, defined as a practice, policy or procedure that results in repeated delays in the adjudication and correct reimbursement of provider claims, as outlined in 28 C.C.R. §1300.71. More than half of practices report that health plans attempt to rescind or modify authorizations after the physician renders the service in good faith. Sixty-two percent report that Anthem Blue Cross is the most problematic when it comes to unfair payment practices; Blue Shield of California was second most problematic (52 percent). The health plan provider dispute resolution processes are largely ineffective, with 32 percent of practices indicating disputes are resolved only half of the time, and 29 percent indicating disputes are rarely resolved through the plans’ internal processes. Though most practices do utilize the health plans’ internal processes to attempt to resolve issues, 63 percent report that plans routinely fail to respond to their appeals within 45 business days of receipt, as required by California law. Anthem Blue Cross is identified as the most problematic (66 percent), with Blue Shield the second most problematic (61 percent). When health plans do respond to physician appeals, 74 percent of practices state the health plan responses do not include a clear explanation for the plans’ determination. These survey results confirm that health plans overwhelmingly continue to engage in unfair payment practices, despite the legislation that passed 18 years ago attempting to stop these abuses. It further demonstrates that, although plans are required to maintain fast, fair and cost-effective provider dispute processes, their processes are largely ineffective. To view the full survey results, click here. To address this issue, CMA is sponsoring AB 2674 (Aguiar-Curry), which would require DMHC to investigate provider complaints that a health care service plan has underpaid or failed to pay the provider in violation of the Knox-Keene Act. If DMHC finds that a health plan has unlawfully underpaid a provider, AB 2674 would require the penalty amount to, at a minimum, equal the amount of the underpayment plus interest. Furthermore, AB 2674 would protect the health care delivery system by ensuring providers are made whole when health care service plans violate the law. The bill would also deter future violations of the law, thereby saving providers and the state vital resources that should be invested in patient care. CMA can help you get paid Physicians are reminded that members have access to CMA’s practice management experts for free one-on-one help with contracting, billing and payment problems. Need assistance? Contact CMA's reimbursement helpline, at (888) 401-5911 or economicservices@cmanet.org. April 5, 2018 CMA, General, Managed Care Department of Managed Health Care, DMHC, Payors, State Legislation, State Legislative Advocacy, Unfair Payment Practices 0 0 Comment Read More »
Health plans terminate contracts with EHS and transition patients to other entities As previously reported, the California Department of Managed Health Care (DMHC) issued a cease-and-desist order on December 26, 2017, requiring nine health plans to terminate their contracts with Employee Health Systems (EHS) Medical Group Inc. This order comes after SynerMed—a company closely affiliated with EHS—was accused of blocking patient access to specialists to hold down costs. EHS has 600,000 patients statewide—90 percent of whom are Medi-Cal managed care patients. As required by DMHC, health plans affected by this order were required to submit a transition plan by January 3, 2018, and have begun the transfer all EHS patients to different health care providers, due to be completed by February 5, 2018. EHS reports to the California Medical Association (CMA) that provider capitation checks for January have been issued and all fee-for-service payments to physicians will continue uninterrupted through the end of January. Additionally, the health plans have representatives onsite at SynerMed to ensure the timely exchange of authorization data and that enrollee and physician inquiries are being addressed appropriately. Other groups affected by the health plan terminations are Multicultural Medical Group, a San Diego based independent medical association acquired by EHS in late 2017, and Inland Valleys IPA, acquired by EHS in 2009. CMA is working with the health plans to ensure claims for services that were authorized by EHS, Inland Valleys IPA and Multicultural Medical Group, but performed after the termination dates, are still honored by the plans. CMA has also requested enrollee transfer documents through a public records request. Physicians should be diligent in obtaining updated insurance information from patients and verifying eligibility at the time of scheduling, if possible, to avoid unnecessary patient confusion and denials of payment for services rendered. Patients may also be able to continue to see their physicians, even if they are not contracted with the patient’s new delegated entity, under California’s continuity of care law. Under continuity of care laws, patients with an acute condition, serious chronic condition, duration of a pregnancy, duration of a terminal illness, care of children between birth and 36 months, or for the performance of a surgery or other procedure that has been authorized, may qualify to request continuity of care. To request continuity of care, patients should call the health plan number on the back of their ID cards. For more information on continuity of care requirements, see CMA On-Call document #7051, “Contract Termination By Physicians and Continuity of Care Provisions.” Practices experiencing problems with EHS, Inland Valleys IPA or Multicultural are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org. February 5, 2018 Managed Care, Medi-Cal Continuity of Care, Department of Managed Health Care, DMHC, Health Plans, Insurance, Medi-Cal, Payor Contracting 0 0 Comment Read More »
DMHC orders 600,000 patients transferred from troubled medical group The California Department of Managed Health Care (DMHC) issued a cease-and-desist order on December 26, 2017, requiring nine health plans to terminate their contracts with Employee Health Systems (EHS) Medical Group Inc. This order comes after SynerMed—a company closely affiliated with EHS—was accused of blocking patient access to specialists to hold down costs. EHS has 600,000 patients statewide—90 percent of whom are Medi-Cal managed care patients. The health plans affected by this order must transfer all EHS patients to different health care providers by early February 2018. The plans were required to submit a transition plan to DMHC by January 3, 2018, with a “Final Proof of Compliance” confirming termination of the plans’ relationships with EHS due by February 5, 2018. In the cease-and-desist order, DMHC describes how SynerMed secretly and systematically blocked patients and providers from accessing contracted specialists deemed too costly. As part of its administration of the EHS provider network, SynerMed provides an electronic online provider portal where contracted physicians can view the available EHS-contracted medical specialists in their region. In June, SynerMed’s CEO issued a “Contracting Playbook” that listed five directives aimed at lowering specialist costs for EHS. In implementing this playbook, SynerMed staff were affirmatively directed to suppress “high cost” providers from the referral system, including cardiologists, diagnostic radiologists, dialysis providers, hematologists, oncologists, nephrologists, ophthalmologists and rheumatologists. According to DMHC, SynerMed actively and secretly restricted “high cost” specialists who maintained contracts with EHS from delivering care to EHS enrollees. Though these specialists continued to maintain contracts with EHS, enrollees as a practical matter had no access to these suppressed providers, which SynerMed unilaterally deemed to be too expensive. Under California law, health plans must notify the state of any policies that deny patients access to contracted providers based on cost — a practice called "economic profiling." Plans must demonstrate that their economic profiling practices would be consistent with the requirement that medical decisions be rendered by qualified medical providers, unhindered by fiscal and administrative management. While there is no indication that the health plans were privy to SynerMed’s effort to narrow EHS’s specialist network, DMHC has found the plans to be in violation of the state law because none of them filed the requisite economic profiling policy. The health plans are working with DMHC to minimize disruption of care, but it is unknown at this time where affected patients will be transferred. It is also unclear how claims processing functions, including preauthorizations, will be handled during the transition. The California Medical Association is working to obtain additional information and will publish an update as soon as we have more details. January 30, 2018 General, Managed Care, Medi-Cal Department of Managed Health Care, Managed Care, Medi-Cal 0 0 Comment Read More »
DMHC IMR/complaint webinar now available on-demand The California Department of Managed Health Care (DMHC), the regulatory agency that oversees 122 health plans, recently conducted a webinar for the California Medical Association (CMA) to provide an overview of the department with a focus on the DMHC Help Center and its Independent Medical Review (IMR) process. DMHC Deputy Director of Health Policy and Stakeholder Relations Mary Watanabe provided an overview of the department’s IMR and complaint processes, including the importance of these processes in the policy, legislative and regulatory arenas. Also provided was information on how to submit the IMR/complaint form to the DMHC Help Center, tips and best practices for assisting patients with access to care, billing issues including denials of care, and overview of the provider complaint unit. This webinar is now available on-demand in CMA's online resource library and is free to all interested parties. July 14, 2016 Managed Care DMHC, Webinars, Department of Managed Health Care 0 0 Comment Read More »
New approval timeframes for prescription drug prior authorizations took effect Jan. 1 A new law took effect Jan. 1, 2016, that requires health plans and health insurers to respond to prescription drug prior authorization requests within 72 hours for non-urgent requests and 24 for urgent requests. The law (SB 282) deems such requests to be granted if the payor fails to respond within these timeframes. A previous law (SB 866) had required a determination within two business days or the request was deemed approved. SB 282 also requires the Department of Managed Health Care and the Department of Insurance to create a standard electronic prior authorization request form no later than Jan. 1, 2017. Prescribers and payors will be required to use and accept this uniform electronic prior authorization form beginning July 1, 2017, or 6 months after the form is developed, whichever is later. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form. A second and related law (AB 374) requires that prior authorization for prescription drug step therapy override requests be submitted in the same manner—and using the same electronic form, when available—as a prescription drug prior authorization requests. Plans and insurer must also respond to such requests within the timeframes set forth in SB 282. Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. January 15, 2016 General Department of Managed Health Care, Preauthorization, Prescription Drugs, Department of Insurance 0 0 Comment Read More »
DMHC fines Blue Shield and Anthem for provider directory inaccuracies On November 3, the California Department of Managed Health Care (DMHC) announced it had fined two of the state's largest health plans for inaccurate Covered California provider directories. Blue Shield of California was fined $350,000, while Anthem Blue Cross was fined $250,000. These two insurers account for almost 60 percent of patient enrollment in Covered California. Both insurers are also utilizing networks for their exchange/mirror products that are significantly narrower than their regular PPO networks. These narrowed networks, combined with inaccurate provider directories, have led to significant confusion and frustration for both physicians and patients. DMHC has directed both plans to improve the accuracy of their provider directories and to also reimburse enrollees who may have been negatively impacted. Blue Shield has already reimbursed more than $38 million to enrollees who incurred out-of-network costs. The fines were the result of a five-month investigation of the Anthem and Blue Shield Covered California networks, which found that more than 25 percent of physicians listed as participating in the plans’ directories were not taking these patients or they were no longer at the location listed by the companies. The audit also found that in both cases, auditors were unable to confirm Covered California participation status for more than 40 percent of physicians listed as participating in the plans’ directories – after three separate attempts to contact them using information in the directory. This hindrance to accessibility for such a substantial portion of listed physicians is a violation of state law, DMHC said in its report. According to the DMHC audit, only 58.7 percent of the physicians listed in Anthem's Covered California directory could be verified as accepting Covered California patients, which is consistent with previous California Medical Association surveys of physicians listed as participating in Covered California. DMHC found that 12.8 percent of physicians listed by Anthem were not accepting Covered California patients, while 12.5 percent were not in practice at the location listed in Anthem’s directory. DMHC has initiated a follow-up survey to determine if the plans have corrected the deficiencies identified in the initial survey reports. You can read the Blue Shield agreement here, and the Anthem agreement here. November 9, 2015 Managed Care Blue Shield, Covered California, Department of Managed Health care, Anthem Blue Cross 0 0 Comment Read More »
Anthem Special Investigations Unit may be recouping beyond statutory timeframe In 2011, the California Medical Association (CMA) raised concerns with Anthem’s attempts to recoup money from physicians beyond the statutory timeframe. Through its Special Investigations Unit (SIU), Anthem was pursuing physicians for refunds of payments made outside of the 365-day period allowed by California law. That law permits recoupment of claims older than a year only if the payment was made based on fraud or misrepresentation. CMA determined that Anthem was employing a definition of “misrepresentation” that was much broader than what is allowed under law. CMA thus filed a formal complaint with the Department of Managed Health Care (DMHC). After reviewing the issue, DMHC issued a cease and desist order to Anthem for violating California’s unfair payment practices law. According to DMHC, between 2008 and 2011, Anthem sought reimbursement from at least 535 providers for claims that were more than one year old, in violation of the Knox Keene Act. Anthem challenged the cease and desist order, and in December 2014 the Sacramento Superior Court issued a judgment that struck down parts of DMHC’s order but upheld DMHC’s and CMA’s interpretation of “misrepresentation.” The Court’s judgment requires that any attempt by Anthem to recoup past the 365-day time limit would violate the law unless Anthem’s recoupment notice clearly explained why Anthem believed the overpayment was caused in whole or in part by either the physician’s fraud or misrepresentation to Anthem. The Court confirmed that “misrepresentation” must be “done without any reasonable ground for believing it was correct.” Since the court’s ruling, CMA has heard reports that Anthem’s SIU is, again, pursuing recoupments beyond the 365-day timeframe for payments made based on misrepresentation. CMA is concerned that the SIU is employing a definition of “misrepresentation” that is not in compliance with DMHC’s cease and desist order and the Sacramento Superior Court’s judgment. CMA is asking physicians to contact its Center for Economic Services if they receive a recoupment request where the payor is attempting to recoup beyond 365 days from the date paid at (916) 551-2061 or jwilliams2@cmanet.org. To help physicians understand their rights and options when it comes to health plan refund requests, CMA has published a "Special Investigations Unit Audit Guide." This document is available free to members in CMA's online resource library. June 26, 2015 General, Managed Care Department of Managed Health Care, Recoupment, Anthem Blue Cross 0 0 Comment Read More »
Blue Shield data breach affects California doctors The Department of Managed Health Care (DMHC) has notified physicians of a data breach that disclosed the social security numbers as well as names, business addresses, telephone numbers, medical groups and practice areas of over 18,000 physicians who contract with Blue Shield of California. DMHC discovered that Blue Shield of California had inadvertently included physician social security numbers in public rosters provided to DMHC. These rosters are generally public documents and subject to disclosure under the Public Record Act (PRA). As a result, DMHC produced the rosters, including the social security numbers, in response to 10 PRA requests made to DMHC between March 2013 and April 2014. DMHC and Blue Shield have instituted additional protections to prevent any future disclosures of confidential physician personal information and recommend that physicians place fraud alerts on their credit files. Blue Shield is also offering affected physicians one-year of credit monitoring services though Experian's ProtectMyID Alert. DMHC's data breach notification letter which includes contact information for three nationwide credit reporting agencies can be found here. For more information on how to protect yourself from identity theft, see CMA On-Call document #1104, "Who's Got Your Number: How Physicians Become The Victims." This document, as well as the rest of the California Medical Association's online health law library, is available free to members in CMA's online resource library. Nonmembers can purchase documents for $2 per page. Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. July 15, 2014 General Department of Managed Health Care, Identity Theft, Blue Shield 0 0 Comment Read More »
Provider access issues plague Anthem and Blue Shield as DMHC begins investigation The Department of Managed Health Care (DMHC) recently began conducting a "non-routine audit" of Anthem Blue Cross and Blue Shield of California to investigate the accuracy of the plans' provider directories and identify whether either plan violated any network adequacy laws. According to the DMHC, consumer complaints about access issues for both plans prompted the investigation. Blue Cross and Blue Shield are the only two exchange plans using narrowed provider networks for their exchange and "mirror" products. The state is looking at whether the networks are too narrow in some counties, making it difficult for enrollees to find participating providers. A California Medical Association (CMA) survey of California physicians found that there is also widespread confusion about exchange plan contracting amongst providers, with 80 percent of physicians stating they had been confused about their participation status. Health plans often use intentionally vague or confusing contracting practices, which result in consumer confusion and frustration, as physicians often do not know that they are listed as participating in certain networks. With roughly 1.4 million Californians newly enrolled in Covered California products since January, it has been difficult for both physicians and patients to identify who is in and who is out of the narrow provider networks. "We remain particularly concerned with indications of disruptions in longstanding doctor-patient relationships, as well as the prevalence of difficulties in finding in-network referrals for patients in these new individual and small group products," wrote CMA President, Richard Thorp, M.D., in a letter to Covered California Executive Director Peter Lee on the issue. "While we understand that the intentionally smaller networks of certain health plans account for some level of expected disruption, we believe other factors, which can be addressed by Covered California and regulators, are contributing to a significant proportion of reported network difficulties." CMA has urged Covered California to address this and other issues before the next open enrollment period. (Click here for more details.) As part of the audit, DMHC has hired pmpm Consulting to contact practices to ask about their participation status with the two plans. If contacted by pmpm Consulting, CMA strongly encourages the practice to respond to their questions. This is an investigation into the accuracy of the plan directories and whether the plans have violated any laws, not an investigation of physician practices. DMHC expects to complete its investigation in approximately 60 days. Findings of the survey will be released publicly prior to the next Covered California open enrollment period, which is scheduled for November 15. Having trouble finding an in-network provider or facility? Patients who are having trouble finding an in-network physician or facility are encouraged to contact the DMHC Help Center at (888) 466-2219 for assistance. We also ask that physicians notify CMA if they are experiencing difficulties finding in-network providers to whom they can refer patients so that we may raise the issue with the plan, Covered California and the appropriate regulator. Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. July 1, 2014 General Department of Managed Health Care, Covered California, Payor Contracting 0 0 Comment Read More »
