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The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.
This article will give providers the information they need to assist consumers as well as themselves with pursuing complaints against health plans.
Sara Jasper, JD Staff Attorney The Therapist July/August 2016 Reviewed October, 2017 by David G. Jensen, JD (CAMFT Staff Attorney)
The Department of Managed Health Care (DMHC), a state agency which oversees the majority of large group commercial health plans and products, small group and individual market plans, as well as most of the Medi-Cal managed care plans, wants psychotherapists and their patients to be aware of the services offered by its Help Center. In 2000, the DMHC and its Help Center was established to primarily serve as a consumer protection agency. The Help Center can be a powerful resource for consumers and providers who have a general grievance against a plan or who have sought a particular service only to have that service denied, modified, or delayed by a health plan. Since its inception, the DMHC’s Help Center has assisted more than 1.6 million Californians to resolve complaints and issues with health plans.
In 2014, the Help Center assisted more than 100,000 consumers. This constituted a 60% increase from the previous year and before the implementation of the Affordable Care Act. Although the DMHC does not yet have an official complaint count for 2015, the Department continued to see significant increases in complaints made last year. As of December 2015, the Help Center’s Provider Complaint Unit had recovered approximately $40 million for California providers. According to DMHC complaint statistics, almost 60 percent of the health plans’ decisions are overturned once the Help Center gets involved. Considering that there are more than 20 million Californians who receive health insurance through DMHC regulated plans, the DMHC’s consumer/provider assistance program appears to be vastly underutilized by consumers and providers.
This article will explain the complaint process and provide information about complaints previously addressed by the DMHC.
The Process for Provider Complaints The Department of Managed Health Care’s (DMHC’s) Provider Complaint Unit (PCU) was created as a way to help providers inform the DMHC about health plan unfair payment patterns. The DMHC will accept provider complaints related to health plans under the DMHC’s jurisdiction (i.e., health plans licensed under the Knox-Keene Act). For a list of health plans licensed under the Act, visit http://wpso.dmhc.ca.gov/hpsearch/ viewall.aspx.
Eligible complaints may be submitted through the Provider Complaint System online at https://wpso.dmhc.ca.gov/provider/ AllLogin.aspx. If you need assistance filing a provider complaint you may contact the PCU by calling their toll-free provider complaint line at 1-877-525-1295. The Provider Complaint System requires providers to register for an account and requires providers include information about themselves, the health plans, the nature of the complaint, specific information about the claim or claims, and supporting documentation. Individual complaints should be submitted using an Individual Provider Complaint Form. Providers who have multiple, similar disputes should complete a Multiple Provider Complaint Form. Providers must be prepared to submit documentation in support of claims complaints. Once a complaint is submitted, the DMHC will send an email acknowledging receipt of a complaint, a complaint number, a list of required supporting documentation and instructions for how to submit the documentation, if necessary. The DMHC will forward all information submitted with the provider complaint form to the payor for a formal response. Claims that are more than four years old from the complaint date will not be considered. Prior to submitting a complaint, provider’s grievances must have gone through the health plan’s Provider Dispute Resolution process or have been in that process for more than 45 working days.
What Happens to Provider Complaints Unfair Payment Pattern and Emerging Trend Analysis will be performed on ALL provider complaints. Trending data will support the routine and non-routine financial examinations performed by the Department’s Office of Financial Review.
How is the Provider Complaint Process Different from the Consumer Independent Medical Review (IMR) and Complaint Process Provider complaints are an avenue for providers to inform DMHC about unfair payment patterns. However, the provider complaint process is different from the options available to enrollees who have a problem with their health plan. Enrollees can apply for an Independent Medical Review (IMR) with the DMHC when a health care service or treatment has been denied, modified or delayed. An IMR is a review the case by independent doctors who are not part of a patient’s health plan. Enrollees have a good chance of receiving the service or treatment they need by requesting an IMR. If the IMR is decided in their favor, the plan must authorize the service or treatment requested. IMRs are free to enrollees.
Enrollees can also file a Consumer Complaint with the DMHC for complaint issues such as balance billing, billing for services the health plan states is not a covered benefit, if the enrollee has a dispute on the amount paid on a claim, a co-pay dispute, cancellation of coverage or for a complaint about the provider’s attitude. Providers can assist enrollees with this process by completing the Authorized Assistant form.
More Information About the Process for Consumer Complaints Except when there is an immediate health threat, or a request for services was denied because it was either experimental or investigational, consumers must first contact their health plan about an issue and exhaust the health plan’s grievance and/or appeal process prior to seeking assistance from the DMHC’s Help Center. The law requires health plans to have a grievance process for resolving consumer complaints within 30 days. Consumers may file complaints with their health plans by phone or via mail. Some health plans also give consumers the ability to file complaints online. Health plan membership cards list a member services number consumers may call to file a complaint (a.k.a. a grievance or an appeal). Health plans’ member services phone numbers and website information can also be found by visiting the DMHC’s website at www.dmhc.ca.gov and clicking on the “ File a Complaint” tab.
Consumers who have an urgent health problem, are not satisfied with their health plan’s decision, or do not receive a decision within 30 days, may submit an Independent Medical Review Application/Complaint Form to the DMHC Help Center. Complaint forms can be accessed online at www.dmhc.ca.gov by clicking on the “File a Complaint” tab and then the “Submit an Independent Medical Review Application/Complaint” link.
Complaints can also be filed by calling the Help Center at 1-888-466-2219. Common complaint issues include balance billing, billing for non-covered benefits, a dispute on the amount paid on a claim, a co-pay dispute, and cancellation of coverage. Consumers also have the option of applying for an Independent Medical Review (IMR) when a service has been denied, modified, or delayed. During an IMR, independent doctors review consumers’ cases to determine whether the service should have been granted by the health plan. If the independent doctors decide a case in favor of the consumer, the consumer’s plan is required to authorize and provide the requested service.
The IMR/Complaint Form is a two (2)-page form which can be filled out on the DMHC’s website at www.dmhc.ca.gov or downloaded from the same website and mailed into the DMHC. The first page of the form requests patient information. The second page asks questions about the patient’s health problem and includes a medical release that gives the DMHC the authority to collect medical records and information from the patient’s past and present providers. Consumers who want to give a person, such as their psychotherapist, permission to assist with their IMR or complaint must complete the “Authorized Assistant Form” which accompanies the IMR/Complaint Form. Records from out of- network providers should be submitted with the form. The plan will provide records from network providers. Other documents that support a service request may also be included. However, consumers should not provide correspondence from the plan regarding the complaint. The DMHC requests that information from the plan as part of its review process. Consumers who have questions about how to fill out the form, may call the Help Center at 1-888-466-2219 or TDD at 1-877-688-9891. The call to the Help Center is free. Those who do not wish to complete the online IMR/Complaint form may mail it and any support documentation to DMHC Help Center, 980 9th Street, Suite 500, Sacramento, CA 95814-2725. Forms may also be faxed to 916-255-5241.
There is no cost to a consumer to file an IMR. Once an IMR/Complaint Form is submitted, the DMHC will send a letter to the consumer within seven days, indicating whether the service request qualifies for an IMR. IMR cases are assigned to a state contractor or Independent Medical Review Organization (IMRO). At that point, all of the consumer’s complaint information is sent to the IMRO. Decisions are usually made within 30 days or within 7 days for an urgent health issue. Consumers are notified in writing of the IMRO’s decision. According to DMHC complaint statistics, nearly 60 percent of consumers receive the services they’ve requested as a result of the IMR process. Under most circumstances, the DMHC will only review IMR/Complaint Form applications that are submitted within six months of a health plan’s written response to a grievance or appeal. Consumers who do not file a complaint with the DMHC for an issue that qualifies for an IMR, may be giving up their right to pursue legal action against the health plan.
Common Complaints The most common consumer disputed/ requesting treatments for Mental Health Independent Medical Reviews include the following:
The most common consumer disputed/ requested treatments for Mental Health Related Standard complaints are:
The most common provider complaints related to the following:
Complaint Reports and Databases Containing IMR and Arbitration Information Another useful tool is the DMHC’s searchable database of IMR and arbitration decisions. Information regarding complaints made against health plans are also available on the DMHC’s website. The IMR database shows all IMR decisions since the IMR program’s inception in January 1, 2001 and can be searched using the name of a drug, treatment, therapy or medical condition. Names and other personal information about patients are not listed. Medical conditions and treatments are listed in general terms. Every IMR is unique and reviewed independently. To access the IMR database, go to http:// wpso.dmhc.ca.gov/imr/. The DMHC’s annual report contains information about the number and types of complaints or grievances received during the calendar year, including Independent Medical Review (IMR) data. The annual reports can be found by going to www.dmhc.ca.gov and clicking on the “File a Complaint” link, and then clicking the “Independent Medical Review Complaint and Reports” link.
When a health plan uses arbitration to settle disputes with its enrollees, the health plan is required to file a copy of the written arbitration decision to the DMHC within 30 days of the decision. The filed copy must include the amount of the award, the reasons for the award and the names of the arbitrators. By law, the names of the plan, enrollee, witnesses, attorneys, provider, plan employees and plan facilities are deleted from the copy filed with the DMHC. These redacted copies of the decisions are filed each quarter. To access the database containing arbitration decisions go to http://wpso.dmhc.ca.gov/ arbitrations/gen_default.aspx.
Mental Health Parity Project Disability Rights California has a statewide prevention and early intervention (PEI) stigma and discrimination grant. As a result, the non-profit has a Mental Health Parity Project that provides information and trainings on mental health parity and individual legal representation to behavioral health clients who believe their rights under state and federal parity laws are being violated. To access Disability Rights California’s facts sheets and other information about mental health parity, visit www.disabilityrightsca.org/CalMHSAParity.html. Those interested in receiving in-person or webinar training on mental health parity or individual help with a mental health parity issue may contact DRC’s Stigma and Discrimination Project Manager and Advocacy Director, Margaret Johnson, either by calling 916-504-5800 or by emailing her at Margaret.jakobson-johnson@ disabilityrightsca.org.
Consumers and providers should turn to the DMHC’s Help Center when experiencing issues with large group commercial health plans and products, small group and individual market plans, as well as most of the Medi-Cal managed care plans, that could not be resolved through the health plans’ appeals/grievance process. For more information about the DMHC’s mission and its Help Center, visit www.dmhc.ca.gov. Disability Rights California also serves as an important resource for those want to better understand their rights and pursue reimbursement for services based on mental health parity laws.