Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx Upon receipt, of the Plan’s annual PAAS submission the Department is required to review the information submitted regarding a plan’s compliance with the timely access standards, make recommendations for changes that further protect enrollees, and post findings from the review on its Web site on or before December 31st of each year. On February 13, 2017, the Department issued All Plan Letter (APL) 17-002 requiring that each plan contract with an external vendor to conduct a quality assurance review of the plan’s data prior to submission. Once an issue is identified by the plan’s External Vendor Validation Report, the APL requires that plan either correct the issue or explain why it cannot be fixed and implement corrective action to ensure that the issue does not recur in future reporting years. The Department contracts with an outside vendor to complete review of all plan PAAS submissions. After the Department’s vendor completes its review of the plan’s submission, the Department sends each health plan a feedback letter requesting a response. In its response, the health plan may include additional information for the Department to take into account in assessing compliance or actions the health plan is taking to ensure compliance in future reporting years. For MY 2017, the Department sent the Plan a feedback letter on October 23, 2018. The letter provided the Plan the opportunity to submit a response to the Department’s feedback no later than December 13, 2018. The Plan failed to report an accurate rate of compliance in the Plan’s MY 2017 PAAS submission, in violation of Health and Safety Code, section 1367.03, subdivision (f)(3); 3 Rule 1300.67.2.2, subdivision (g)(2)(B). Section 1367.03, subdivision (f)(2), requires plans to submit annual reports demonstrating compliance with timely access standards. Pursuant to Section 1367.03, subdivision (f)(3), the Department has adopted standardized methodologies which plans are required to follow when conducting and preparing the PAAS submission. As part of the MY 2017 PAAS Methodology plans were required to submit a rate of compliance with the time-elapsed standards set forth in Rule 1300.67.2.2, subdivision (c)(5) separately for each required provider type. (Cal. Code Regs., tit. 28, § 1300.67.2.2, subd. (g)(2)(B).)
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx Plan re-reviewed the file, this time concurring that the services were emergent in nature. The Plan reprocessed the service under the enrollee’s emergency services benefits, leaving the enrollee with a zero balance, thereby resolving the enrollee’s Help Center complaint. The Plan failed to adequately consider and rectify the enrollee’s grievance. (Health & Saf. Code, § 1368, subd. (a)(1).) Health and Safety Code section 1368, subdivision (a)(1), requires a plan to maintain a grievance system that ensures adequate consideration of enrollee grievances and rectification when appropriate. In this case, the enrollee filed a grievance with the Plan and clearly indicated that the enrollee was at an in-network emergency facility. Despite this explicit statement, the Plan’s grievance analyst failed to consider whether the services rendered were actually for emergency services. Accordingly, the Plan failed to adequately consider and rectify the enrollee’s grievance, in violation of Health and Safety Code section 1368, subdivision (a)(1). The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that an administrative penalty of $7,500 is warranted. The Department agrees that payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. In summary, the statute(s) and/or regulation(s) prosecuted herein are: • Health and Safety Code section 1368, subdivision (a)(1). / / / / / / / / / / / / / / / / / / / / / / / / This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: November 16, 2022 /Original Signed/ Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by Blue Cross of California Dated: October 17, 2022 /Original Signed/ Xxxxx Xxxxxx Associate General Counsel Blue Cross of California
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx Upon receipt, of the Plan’s annual PAAS submission the Department is required to review the information submitted regarding a plan’s compliance with the timely access standards, make recommendations for changes that further protect enrollees, and post findings from the review on its Web site on or before December 31 of each year. On February 13, 2017, the Department issued All Plan Letter (APL) 17-002 requiring that each plan contract with an external vendor to conduct a quality assurance review of the plan’s data prior to submission. Once an issue is identified by the plan’s External Vendor Validation Report, the APL requires that plan either correct the issue or explain why it cannot be fixed and implement corrective action to ensure that the issue does not recur in future reporting years. The Department contracts with an outside vendor to complete review of all plan PAAS submissions. After the Department’s vendor completes its review of the plan’s submission, the Department sends each health plan a feedback letter requesting a response. In its response, the health plan may include additional information for the Department to take into account in assessing compliance or actions the health plan is taking to ensure compliance in future reporting years. For MY 2017, the Department sent the Plan a feedback letter on October 23, 2018. The letter provided the Plan the opportunity to submit a response to the Department’s feedback no later than December 13, 2018.
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx California Physicians' Service October 24, 2022 Xxxxx Xxx Xxxx 2 of 2 Here, the Plan’s delegate, Xxxx, received the request from the provider on November 4, 2020, and made its decision seven business days later, on November 13, 2020. Xxxx failed to make a decision to approve, modify, or deny the treatment request from the enrollee’s provider within five business days of receipt in violation of Section 1367.01, subdivision (h)(1). Health care service plans do not waive their obligation to comply with the Xxxx-Xxxxx Act, even when services are delegated to medical groups. (Health & Saf. Code, § 1367, subd. (j).) The Plan is subject to discipline pursuant to Health and Safety Code, section 1386, subdivision (b)(6) for the violation of a section of the Xxxx- Xxxxx Act. In settlement of this enforcement matter, the Plan has agreed to accept an administrative penalty for Xxxx’x violation of a section of the Xxxx-Xxxxx Act. The Plan has acknowledged its delegate Xxxx’x failure to comply with the Xxxx-Xxxxx Act in this enforcement matter. The Department has determined that an administrative penalty of $5,000.00 is warranted. The Department agrees that payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or proceeding by the Department involving the Plan. In summary, the statute prosecuted herein are: • Health and Safety Code section 1367.01, subdivision (h)(1). This agreement contains the entire understanding among the parties and supersedes any prior understandings and/or written or oral agreements among them respecting the subject matter within. Sincerely, Dated: December 5, 2022 / Original Signature / Xxxxx X. Xxxxxxxxx Deputy Director | Chief Counsel Office of Enforcement Accepted by California Physicians' Service Dated: November 8, 2022 / Original Signature / Xxxxx Xxx Associate General Counsel California Physicians' Service BYW:slt
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx The enrollee filed a complaint with the Department’s Help Center on January 22, 2021. During the Help Center’s inquiry, the Plan reached out to the enrollee’s medical group. AllCare IPA agreed that the post-surgical appointment should have been covered as part of the global surgical authorization. The Plan then reprocessed the claim on February 12, 2021. The Plan was in violation of Health and Safety Code section 1386, subdivision (b)(1), when it denied the post-surgical follow-up appointment claim. A health care service plan is subject to discipline when it is determined to be operating at variance to the basic organizational document filed pursuant the Section 1351 or 1352. (Health & Saf. Code, § 1386, subd. (b)(1).) Plan Evidence of Coverage are required to be filed and approved by the Department pursuant to Section 1351, subdivision (f). The enrollee’s applicable Evidence of Coverage (EOC) states: “If you receive a bill for a Covered Health Care Service from a Physician who is not one of our Network Providers, and the service was prior authorized and you have not exceeded any applicable benefit limits, UnitedHealth Care will pay for the service, less the applicable Co-payment/Deductible.” (EOC, pp. 54-55.) The enrollee was issued authorization for surgery with a non-network provider. The enrollee’s medical group admitted that the post-surgical appointment should have been covered as part of the authorization for surgery. However, the claim for the post-surgical appointment was denied as not authorized contrary to the terms of the enrollee’s EOC. As such, the Plan, in denying the claim, acted at variance with the EOC, and is subject to discipline. The Plan has acknowledged its failure to comply with the Xxxx-Xxxxx Act and title 28 of the California Code of Regulations in this enforcement matter. The Department has determined that a Corrective Action Plan (CAP) and an administrative penalty of $7,500 are warranted. The Department has accepted the CAP proposed by the Plan as detailed below. The Department agrees that performance of the CAP to the Department’s satisfaction and payment of the penalty will settle all issues, accusations, and claims pertaining to this enforcement matter. This agreement and the violations set forth herein may not be used as an admission against the Plan in any civil or criminal proceedings; however, they may be considered and used in any future action or p...
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx The Plan’s discovery responses described the Plan’s long and complicated history with the DOC. The Plan was originally formed in 1974 under the Xxxx-Xxxxx Health Plan act of 1974 (Xxxx-Xxxxx Act). The Department’s limited records indicate that in 1986 the DOC requested the Plan to provide documentation that it was engaged in reimbursement under the Xxxx-Xxxxx Act. The Plan provided two documents to the DOC that the Plan asserts demonstrated it offered indemnity products under the Xxxx- Xxxxx Act. The Plan alleges that its EPO and PPO products fell under such indemnity products. The Plan’s discovery responses stated that the Director of the DOC informed the Plan that it may operate and sell reimbursement (indemnity) products without filing for approval from the DOC so long as the indemnity products accounted for less than 10% of the Plan’s total expenditures. The Plan stated that it relied on this guidance and did not file any of its indemnity products with the DOC or the Department. The Plan further provided correspondence from 1996 indicating that the DOC also informed the Plan that it was not required to file EOCs for its indemnity products. A 2001 correspondence showed that the Plan asked the newly formed Department to confirm that it was exempt from filing a notice of material modification for its point-of- service (POS) products, pursuant to Health and Safety Code section 1374.71.1, 2 The Department’s licensing records between 1976 and 1993 of the Plan were inadvertently destroyed, so the Department cannot confirm nor refute most of the Plan’s assertions. The Department agrees that the Plan appears to have been exempt by the DOC from filing its POS products and EOCs for approval. However, the Department disagrees that this “indemnity product exemption” extends to the Plan’s current offering of EPO and PPO products. The Plan’s EPO and PPO EOCs refer to the Department as the regulator and that enrollees may contact the Department to file a grievance. However, the Department has not specifically approved these EOCs, and the EOCs themselves are out of compliance with the Xxxx-Xxxxx Act in several aspects and have not been updated to reflect statutory and regulatory changes over the past few years. On or about May 25, 2022, the Plan decided to discontinue the EPO product and, where feasible, will decline to renew existing enrollees. The Plan has 19 small groups with EPO contracts, with...
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx On June 16, 2022, the enrollee contacted the Plan again regarding Claim One and the lack of follow up she had received about the steps taken to resolve the issues with Claim One. The enrollee was informed that the Plan was opening a grievance, but it was later confirmed that this grievance was closed out despite the enrollee never receiving any formal response from the Plan. On or around June 22, 2022, however, the Provider submitted the requested medical records. When the Plan received these records, it processed them as a new claim (Claim Two) and incorrectly denied the enrollee’s claim as a duplicate claim. The Provider proceeded to bill the enrollee for the full cost of the office visit, $286, and later informed the enrollee that she could not be seen until the claim was paid. On June 24, 2022, the enrollee contacted the Plan yet again to address issues with Claim One. The enrollee stated that her Provider asserted that the Plan’s Provider Services Team advised the Provider that Claim One was denied in error; however, the enrollee had just received confirmation that the Plan was upholding its original denial of Claim One. The enrollee also referenced a claim from May 2022 from the same Provider for the same services that the Plan accepted and paid. The enrollee repeatedly asked for help as she could not afford to pay the billed charges of $286 for the services. The Plan failed to recognize this communication as a grievance and did not open a grievance level review. On June 27, 2022, the enrollee sent in the bill she received for Claim One as well as notes from her call with office staff. On June 29, 2022, the Plan representative confirmed receipt of the information and informed the enrollee the matter had been escalated. The Plan failed to recognize this communication as a grievance and did not open a grievance level review. On July 3, 2022, the enrollee requested confirmation that the Plan was still handling Claim One, and the Plan’s representative confirmed that there was still an escalation for that claim. On July 22, 2022, the enrollee requested an estimated date that the escalations would be finalized, noting that the Claim One was going on 120 days past due, would be sent to collections, and would ultimately affect her credit. A Plan representative informed the enrollee that the escalation could take several weeks and suggested that she ask the Provider to put her account on ...
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx On December 29, 2021, the enrollee filed a complaint with the Department’s Help Center. The Plan reiterated in its initial response that the claim was forwarded to the medical group in error and that the Plan had approved the claim payment in the amount of $253, but Medicare needed to process the claim first. After additional inquiries from the Help Center, the Plan confirmed that the enrollee does not have Medicare part B, which is what would cover urgent care services, but has Medicare parts A & D. As such, the Plan was the primary payor on the claim and the Plan agreed to process and pay the claim minus the enrollee’s $20 copay. The Plan acknowledged the claim had been processed manually and the claims representative had mistakenly identified the enrollee’s Medicare coverage as part B, when in fact the enrollee had Medicare parts A & D.
Million Californians. Contact the DMHC Help Center at 0-000-000-0000 or xxx.XxxxxxXxxx.xx.xxx In February 2021, the enrollee filed a grievance with the Plan, asserting that the Plan should have processed the claim as an emergency service. In March 2021, the Plan reviewed the claim and upheld its processing based on the Place of Service code, despite the enrollee’s claim that the services were emergent in nature. In April 2021, the enrollee contacted the Plan and filed a second grievance. The Plan reviewed the grievance, and in May 2021, the Plan noted that the grievance was a repeat of the enrollee’s previous grievance. The Plan upheld the prior denial, advising the enrollee to contact the Department’s Help Center. The enrollee contacted the Department’s Help Center in May 2021. The Plan response to the Help Center’s initial request for health plan information was consistent with the Plan’s prior analysis. However, after the Help Center had additional interactions with the Plan, the Plan overturned its previous denial and reprocessed the claim under the enrollee’s emergency services benefit. In this case, the Plan does not contest that the services in question were performed in connection with the delivery of emergency care; the enrollee was pregnant and experiencing complications and, accordingly, the provisions relating to Emergency Services would apply. The Plan appeared to assert that its initial decision to impose a $250 deductible and $1,000 coinsurance was correct until the Help Center intervened. However, the applicable provision of the Schedule of Copayments indicated that the enrollee’s financial responsibility was $50 for emergency services delivered in an urgent care or outpatient care setting. Moreover, the Plan’s assignment of the $1,000 coinsurance to the enrollee also contradicted the cost sharing amounts contained in the Schedule of Copayments, which states that the emergency room copayment will be waived if admitted to the hospital directly from urgent care or an emergency room. Accordingly, the Office of Enforcement determined the following: The Plan’s application of the incorrect copayment amount constituted an operation at variance with the applicable EOC, in violation of Health and Safety Code section 1386, subdivision (b)(1). Under Health and Safety Code section 1386, subdivision (b)(1), administrative discipline is warranted when a health plan acts at variance with its filed documents, including at variance with its EOC. / / / / / / / / / The applicable ...
