Managed Care: Dealing with Problems Kern Health Consumer Center January 27, 2005

Problems that can arise Requested services denied or reduced Insufficient notice, decision incorrect or based on non-medical criteria Lack of access to providers & specialists Not enough in the network, transportation, physical barriers, difficulties in getting referrals Billed for services that health plan should pay for Quality of care issues Poor care, interpretation/translation, culturally appropriate care, rudeness Consumers may not understand the system Navigating the system, dealing with “no”, finding information about the system for self-education

Who is Responsible? Medical Office level Health Plan Level Report the problem If serious, inform health plan as well Ask to be informed of the resolution If not addressed, go to the next level Health Plan Level Starting point for denials of care, referral problems, lack of access

Grievance and Appeals Options by Program Medi-Cal (Department of Health Services) Fee for Service Fair Hearing State or Federal Court (Writ) Managed Care In-Plan Grievance HEALTHY FAMILIES PROGRAM (Managed Risk Medical Insurance Board MRMIB) Department of Managed Health Care (DMHC) State-Developed Healthy Families Appeals Process* Managed Care Program Only Independent Medical Review (SCHIP: External Review) Private Insurance HMO, POS In-Plan Grievance Department Of Insurance PPO Complaint to Insurer Fee for Service (Indemnity)

Appealing a Denial of Care Grievance Process Each plan has its own, may call it something else Fair Hearings (Medi-Cal only) Beneficiaries entitled to a fair hearing to the same extent as in fee-for-service Filing a grievance does NOT toll the time for filing for a fair hearing Can do one or both at the same time—may be a strategic decision, may also depend on who made the decision.

Independent Medical Review Only for people in HMOs and POS Must do a grievance first, get decision or wait 30 days (unless it must be expedited) For denials based on medical necessity, or experimental/investigational procedure. Also for reimbursement of emergency or urgent care. IMR filed through the Dept. of Managed Health Care (DMHC) Review form and supporting documentation reviewed by appropriate medical specialists Health plan MUST follow the decision, including any reimbursement to patient

Medical Billing Problems Who is billing—the provider or the plan? Can it be resolved with a phone call or letter? Is this a pattern or frequent problem? Should it be reported to the health plan or to a state regulator? Is the provider failing to submit the required paperwork or submitting with errors? Does the patient understand how to use the managed care plan? Did the patient show his/her health card? Is the patient going out of network unnecessarily? Is the patient unable to get the proper care within the network? Why? Always check the Evidence of Coverage booklet

Medi-Cal Billing Issues Medi-Cal is full payment Providers should not bill for anything other than co-payments or services that Medi-Cal does not cover at all When the provider in the care continuum is not a Medi-Cal provider Must address this with the referring provider for immediate resolution Hospitals should make sure that Medi-Cal beneficiaries have the same access to care as other patients Medi-Cal pays after other types of insurance Problems coordinating Medicare or private insurance coverage that should pay first Make sure that providers accept both types of insurance

Medi-Cal Billing Issues Retroactive Medi-Cal Medi-Cal can pay for services obtained in the three months prior to application Make sure that provider knows about the patient’s retro coverage Medi-Cal provider should bill Medi-Cal, then return the patient’s money