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

2. 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

3. 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

4. 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)

5. 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.

6. 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

7. 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

8. 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

9. 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