Sara Jasper, JD,
Staff Attorney
The Therapist
March/April 2015

The first Consumer Provider Plan Agency meeting of 2015 was held in Sacramento at the Department of Managed Health Care (DMHC) on January 16th. During the first half of the meeting, the Director of the Department’s Help Center, Dan Southard, gave a presentation to the group about the processing of complaints from consumers and providers. Below is a summary of his presentation as well as information about CAMFT’s request for the Department to take action against health care plans that are violating the state’s telehealth laws by not treating these services just like face-to- face therapy sessions.

Help Center’s Contact Information
The Help Center’s toll-free phone number is 1-888-466-2219. Providers and clients can also visit the Help Center’s website at www. HealthHelp.ca.gov.

Regulatory Functions of the DMHC
The Department’s regulatory functions include plan licensing, consumer/provider assistance, plan surveys, financial audits, and enforcement. There are more than 20 million Californians who receive their health insurance through DMHC regulated plans.

Clients and/or providers can request authorization for services. Plans have 72 hours to respond to expedited authorization requests and five business days for non-expedited resources. Plans can deny requests as not medically necessary, experimental/investigational, non-urgent/emergent, or not a covered benefit. Plans must issue denials in writing and advise enrollee of the grievance process.

Providers and/or clients should be filing appeals with the health plans first, as part of an internal review process, and if the appeal is denied, then filing a grievance with the Department as part of the external review process. There are a few different types of complaints the Department receives. These include complaints that are urgent and require quick resolutions. There are standard complaints and there are Independent Medical Reviews, otherwise known as “IMRs.” IMRs are “fast, free, and final.” Within the past two years, 57 percent of IMRs filed resulted in health plans’ decisions being overturned or in health plans reversing their original decisions.

It’s important to note that a provider cannot sign and/or date a request for an Independent Medical Review. The consumer or the consumer’s legal representative must sign the request. For complete details on the IMR process, see Dave Jensen’s article titled, Independent Medical Review: A Slingshot in Your Patient’s Battle With the Goliath of Managed Care on the CAMFT website at www.camft.org.
Although the Provider Complaint Unit (PCU) does accept complaints from providers, the PCU does not have the legislative/statutory authority to investigate individual complaints from providers. The unit only collects complaints in order to determine and track complaint trends which goes to the Department’s auditing groups. Since provider’s individual complaints are not investigated, Mr. Southard stressed the importance of having the consumer or the consumer’s representative file a complaint if the consumer/provider wants prompt action to be taken. CAMFT recommends that both consumer and providers file complaints when possible so that the consumer’s individual issues can be reviewed and so that complaint trends can be identified by the Department. The phone number for the Provider Complaint Unit is 1-877-525-1295. The PCU’s email address is pcu@dmhc.ca.gov.

Help Center Monthly Statistics for 2014
Each month, the help center answers more than 8,000 calls and receives more than 800 standard complaints. The Department handles more than 125 urgent/quick resolution cass and receives 250 IMR applications each month.

Reimbursement for Telehealth Services
CAMFT continues to receive calls from members whose claims for telehealth services are being denied by the health care plans that are regulated by the DMHC. During the second half of the meeting, CAMFT shared this information with the group and gave a presentation on the issues providers are facing as well as its interpretation of the telehealth laws. Prior to the meeting, CAMFT wrote a letter to the DMHC’s Director, Shelley Rouillard, to formally request that the Department look into this issue. In addition to Mr. Southard, a lawyer from the Department’s Office of Legal Services was present. Both asked that CAMFT provide them with specific examples of claim denials for services. (Note: Following the meeting, CAMFT sent an email blast to all members requesting copies of denials for these services.)

The representatives from Blue Shield, Magellan, UBH, and Value Options offered to send CAMFT information regarding their telehealth policies. CAMFT requested that all of the plans who participate in the work group send CAMFT their plans’ telehealth policies.

At the next meeting, the group will discuss the top 10 barriers to access issues and requests from health plans for letter/Explanation of Benefits from Medicare regarding reimbursement denials. The group will also review the health care plans’ definitions of, and guidelines for determining medical necessity.

Sara Jasper, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.