DMHC Fines Delta Dental $250,000
The California Department of Managed Health Care has fined Delta Dental $250,000 for failing to resolve claims in an appropriate manner.
According to correspondence between the agency and the San Francisco-based insurer, Delta failed to pay interest and penalties on 60% of late claims that were included in a sample of 50 late claims, as well as when a provider dispute was found in the favor of a provider. Delta also failed to pay all interest and penalties due when a provider dispute was determined the provider's favor 56% of the time.
Delta was also just below the 95% compliance threshold in denying claims within the statutory deadline; stating the correct reason for denying a claim; and failing to acknowledge provider disputes in a timely manner.
The survey of claims took place in 2013, and Delta had already agreed to and implemented a plan of correction, according to the correspondence.
In other regulatory actions, the DMHC fined Cigna Healthcare of California $70,000 for engaging in a protracted dispute in 2011 with an unnamed contracted provider. As a result, “enrollees experienced a 14 week disruption in continuity of covered speech and occupational therapy services.”
According to the agency, in one case Cigna dragged its feet responding to a grievance filed by the mother of one of the enrollees. Partly as a result, the contracted medical group initiated collections against the family for co-payments, even though the household had met its out-of-pocket maximum.
The DMHC determined Cigna failed to provide a continuum of care, didn't provide timely access to healthcare services, failed to respond to an enrollee's grievance and took no actions to prevent balance billing by the provider.
In addition to paying the penalty, Cigna agreed to a plan of correction and “counseled the front line staff who handled the transition to a new occupational therapist for the enrollee.”
Anthem Blue Cross of California was fined $35,000 by the DMHC for a 2011 incident in which the health plan took weeks to respond to the parents of an enrollee's request for occupational therapy for their 2-year-old child, even though the child's primary care physician approved the services.
