Accountable, DMHC Settle Charges
The Department of Managed Health Care has reached terms with a Signal Hill-based medical group it had accused earlier this year of allowing non-medical professionals to make prior authorization decisions regarding care.
The DMHC had issued a cease-and-desist order against the Accountable Health Care IPA last July. It claimed two of its employees, including the son of Chief Executive Officer George Jayatilaka, M.D., had been making medical necessity decisions for patients even though they lacked the proper credentials to do so. Only a licensed physician has the authority to make such decisions by law.
Druvi Jayatilaka and Ambarish Pathak had been conducting medical necessity reviews and making decisions about patient care between December 2008 and when the DMHC issued its order, according to records. At the time the order was issued, Accountable was providing care to 148,000 patients from nine different health plans under a risk-bearing arrangement.
As part of the settlement, which was reached on Oct. 4 and is known as a stipulated agreement, the cease and desist order was replaced by a consent decree.
Under the terms of the agreement, Accountable has agreed to install an outside monitor to ensure it is brought into compliance with the laws regarding prior medical authorizations. The monitor, Frank Stevens of the Berkeley Research Group’s Los Angeles office, will also conduct audits to determine the specific relationship between the health plans that contracted with Accountable and their enrollees whose care were affected by its decisions.
DMHC spokesperson Marta Green said that the agency had appointed monitors in the past, but that it was relatively rare. Both Stevens and Berkeley has provided such services on behalf of the DMHC in the past, Green added.
Accountable will pay for the monitor for at least three years, although Stevens and the Berkeley Group will answer only to the DMHC. Accountable has also agreed to follow any recommendations made by monitor and the DMHC.
Care managers approved by the DMHC will also be appointed by Accountable to any patients whose care may have been impacted by faulty medical necessity decisions.
Accountable also agreed to undergo a prospective review of all claims it has handled since January 2009 and make up any improperly reconciled payments and interest.
Additionally, Accountable will make a voluntary $500,000 grant over the next two years to an organization that provides care to uninsured or underinsured individuals.
Should Accountable breach the agreement with the DMHC, the agency reserves the right to re-delegate the lives it is managing to other risk-bearing providers. Accountable would not be entitled to a hearing prior to such a decision.
