The California Department of Managed Health Care (DMHC) has taken enforcement action including $1,205,000 in fines against Blue Cross of California Partnership Plan, Inc. (Blue Cross) for its failure to timely implement two Independent Medical Review (IMR) determinations to authorize coverage for medically necessary services. The Medi-Cal managed care plan confirmed receiving the Department’s notifications of the IMR decisions but failed to timely authorize the enrollees’ services.
“The DMHC Help Center’s appeals process, called an Independent Medical Review, is a critical protection for health care enrollees. The Independent Medical Review is a backstop to ensure health plans cover medically necessary health care services enrollees are entitled to receive,” said Acting DMHC Director Mary Watanabe. “It is a serious violation when a health plan fails to follow the Independent Medical Review decision and cover the required medical services. This mandated fine is needed to prevent similar violations from happening in the future.”
California law requires health plans to authorize the services within five working days of receiving an IMR determination accepted by the Department. Health plans are subject to a fine of no less than $5,000 for each day that an IMR decision is not implemented.
Two Medi-Cal Blue Cross enrollees in Northern California requested coverage for a consultation for transgender related procedures. The plan’s delegated medical provider group denied the enrollees’ requests. In both instances, the enrollees filed a grievance with Blue Cross, and the plan upheld the medical group’s decision to deny the requests. The enrollees then filed an IMR appeal with the DMHC’s Help Center. The independent reviewer determined the consultations were medically necessary for each enrollee, and the plan’s denials were overturned.
The Department adopted the IMR determinations and immediately informed the plan. In both cases, the plan acknowledged the IMR determinations in correspondence to the enrollee. However, months after the Department applied the IMR determinations, the enrollees contacted the DMHC saying that they were still having problems obtaining the services. After the DMHC Help Center intervened, the enrollees were able to get the services they needed. In one case, the service was not authorized until 200 days after the plan was legally required to authorize the service. Due to this delay, the plan has been fined $1,000,000. In the second case, the service was not authorized for 41 days after the legal requirement and the plan has been fined $205,000 for that violation.
Blue Cross has acknowledged its failure to comply with the law and has agreed to pay the fine and complete a Corrective Action Plan to settle the issue. The plan has updated their internal policies to ensure proper IMR handling in the future.
Californians enrolled in health plans regulated by the DMHC have the right to appeal their health plan’s decision by applying for an IMR if their plan denies, changes, or delays their request for medical services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment for a serious medical condition. During an IMR, doctors who are independent and do not work for the health plan will examine the case to see if the health plan appropriately denied services, or if the enrollee should receive the requested service or treatment. If it is determined that the health plan should not have denied the enrollee’s request, the plan must cover the service or treatment.
If a health plan enrollee is having trouble getting the care they need, they should file a grievance with their health plan. If the enrollee does not agree with their health plan’s response or the plan takes more than 30 days to fix the problem, they can file a complaint or apply for an IMR with the DMHC Help Center at www.HealthHelp.ca.gov or 1-888-466-2219.
This article was released by the California Department of Managed Health Care.