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, ... 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 ... 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, ... 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 ... 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 ... 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 ... 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 ... 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 ... 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 ... 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 ... July 1, 2014 General Department of Managed Health Care, Covered California, Payor Contracting 0 0 Comment Read More »
