More Big Health Plan Fines From DMHC
The California Department of Managed Health Care is ending 2014 with a regulatory flourish, handing down five five-figure fines totaling $132,000 during the first few days of December.
The biggest penalty was levied against Oakland-based Kaiser Foundation Health Plan. It was fined $75,000 for its 2010 refusal to provide a response to a patient grievance within 72 hours and a series of violations related to that incident.
The patient, who had requested a surgical procedure, said she was suffering severe pain – a condition that had been mentioned multiple times in her medical records, according to the DMHC. “Because both the enrollee's grievance and her medical records indicated that she was experiencing severe pain, she was experiencing an imminent and serious threat to her health,” the DMHC concluded, meaning Kaiser violated the state Health & Safety Code in a variety of ways by not honoring her request for an expedited response. It also ruled that Kaiser failed to issue a timely acknowedgement of her grievance. And when the DMHC asked for additional information about the patient's case, Kaiser did not indicate when it would give the agency the information it was seeking, which constituted another violation.
Moreover, the DMHC had also concluded Kaiser had improperly trained staff who handle enrollee grievances, erroneously informing them that they do not have to provide expedited responses when a claim of severe pain is involved.
In addition, the DMHC fined MD Care $25,000 for its failure to notify the agency last year that it was consolidating its Medicare Advantage operations with Humana, as well as other statuatorily required notifications. MD Care agreed to submit paperwork regarding the movement of its enrollees to Humana and the surrender of its license, while Humana agreed to submit a separate filing regarding the transition of the enrollees.
Western Health Advantage was fined $12,000 for violating its own enrollee evidence of coverage guidelines when it denied a 2012 request by two recent enrollees to continue to receive care from an out-of-network pain management provider. The plan also did not answer questions when the DMHC asked for specific information.
Blue Shield of California was fined $20,000 for two incidents when the San Francisco-based insuer did not respond to an enrollee's grievance in a timely manner. Both incidents drew $10,000 fines.
So far this year, the DMHC has issued 156 penalties against health plans and providers, and levied just over $3.95 million in fines, or more than $25,320 per citation.
In 2013, the agency issued 121 penalties and levied fines totaling $5.62 million. Of those fines, $4 million were levied against Kaiser for lapses in its behavioral health services.
That large penalty aside, the fines being levied by the DMHC this year have been of an increasingly larger variety since Carol L. Ventura was appointed the agency’s enforcement last year.
Ventura replaced Anthony Manzanetti not long after Payers & Providers reported last year that fines and enforcement actions dropped dramatically after his appointment in December 2011.
In calendar 2011, the DMHC had issued more than 500 enforcement actions. In calendar 2012, that dropped to 90, with an average fine of just over $5,000 -- less than a fifth of the average fine that has been levied to date so far this year.
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