DMHC Opens Consumer Portal

The California Department of Managed Health Care has launched an online portal to allow consumers to file grievances regarding health plans and affiliated providers in a more convenient and timely manner.

Officials said that the anticipated expansion of enrollees in commercial and Medi-Cal managed care plans in the coming years prompted the launch of the portal.

“With more Californians to gain healthcare coverage under the Affordable Care Act, this new online portal will ensure there is a fast and easy way for them to get the care they are entitled to,” said Diana S. Dooley, secretary of the California Health and Human Services Agency.

The portal form asks for pertinent information such as the patient's name, personal address, ethnic background and the issues surrounding a denial of care from their health plan or provider. It also asks the individual how they would like the grievance resolved, and authorizes the disclosure of the enrollee's medical records.

According to the agency, it received more than 43,000 telephonic inquiries from consumers in 2011. That led to more than 4,100 formal complaints and more than 1,700 independent medical reviews, wherein the DMHC retains a physician not affiliated with the agency to determine the validity of the grievance and whether the health plan must pay for care. 

Grievances center on issues related to whether a plan should pay for a treatment it considers investigational, whether the plan considers a treatment medically necessary, or whether the enrollee should be reimbursed for a visit to an emergency room.

According to DMHC data, about 60% of such grievances resulted in a favorable outcome for the enrollee last year. About 40% of IMRs resulted in a reversal of the health plan's initial decision by the agency last year, with another 19% overturned by the plan itself.

The portal was launched from a federal grant that was awarded in connection with the ACA, agency officials said.