DMHC Fines Western Dental $110,000

The Department of Managed Health Care has fined the Orange-based Western Dental Services dental insurance plan $110,000 for failing to pay its providers in a timely manner and for neglecting to pay the regulator a special assessment, records show.

The DMHC dinged Western Dental $80,000 because it failed in the first quarter of 2013 to report enrollees who received services from its provider network.

According to the agency, Western Dental provided services to enrollees of another plan as part of an arrangement with that payer and it was required to list those enrollees in its quarterly financial statements. As a result, Western Dental underreported its enrollment by 110,293 and therefore underpaid its enrollment-based assessments by $39,359.12. Western Dental refiled its financial reports for the first three quarters of 2013 and agreed to  include assigned enrollees in its future reports.

Western Dental reported enrollment of 421,2183 in its latest financial report to the DMHC. Of that total, 263,287 were reported as being contracted from other dental plans.

The DMHC also fined Western Dental $30,000 for failing to pay the correct interest and penalties on disputed claims when they were finally adjudicated, and often failed to make payments in a timely manner. The issues were discovered during a routine audit of the plan that took place last year. Western Dental agreed to provide additional staff training and auditing services in order to correct the issues.

The penalties and the fines paid by Western Dental cannot be used in any civil or criminal proceedings against the plan, but can be taken in consideration against the plan in future DMHC actions.

In other actions, the DMHC fined San Francisco-based Blue Shield of California a total of $35,000 for three separate violations. That included a $15,000 fine for a 2012 incident wherein a pregnant enrollee whose child was diagnosed in utero with cardiac abnormalities. 

According to records, the plan did not accommodate the patient’s request that she give birth at a hospital with a neonatal intensive care unit and an OBGYN who specializes in high-risk deliveries. 

Blue Shield was also fined for not responding to enrollee grievances and for not providing records to the DMHC in a timely fashion.