DMHC Fines Kaiser $195,000
The California Department of Managed Care (DMHC) has fined Kaiser Foundation Health Plan $195,000 for 35 violations of state regulations regarding the handling of enrollee grievances.
According to the DMHC, Kaiser was cited for 27 instances of failing to handle grievances in an appropriate manner, and eight other instances of not providing the agency information regarding the grievances in a timely manner.
In addition to the fine, Kaiser also agreed to a corrective action plan. It included additional training for staff that handle grievances and improvements in the enrollee grievance reporting process.
The DMHC also fined Anthem Blue Cross of California $47,500 for failing to cover out-of-network emergency care costs for an enrollee, claiming the care she received was non-emergency in nature. Anthem also failed to provide related medical records to the DMHC in a timely manner after the enrollee filed a grievance with the agency. DMHC said it only received the information after it made “multiple requests.”
In addition to the fine, Anthem agreed to discuss the deficiencies with the employee responsible for handling the claim and their supervisor.
In another agency matter, the DMHC ordered First Choice Medical Group of Fresno to stop enrolling new members and Woodland Hills-based Health Net from allowing new enrollees to use First Choice's provider network.
According to DMHC, First Choice has not been able to maintain mandatory solvency ratios of having 75 cents cash on hand to cover each dollar of pending claims since last year. The correction plans submitted by First Choice have also contained numerous errors. On July 11, the day the DMHC issued the order, it said it had yet to receive an acceptable correction plan even though at least four had been submitted by First Choice.
First Choice and Health Net have until Aug. 15 to submit a plan detailing how new enrollees are not being assigned to the former.
