Frequently Asked Questions
Claim Payment Problems
What Should I Do If I Have A Problem Getting Paid By A Payor?
The Knox-Keene Act and its implementing Regulations require each Health Care Service Plan to provide "a fast, fair and cost-effective dispute resolution mechanism under which providers may submit disputes to the plan". You should always first try to resolve your concern directly with the Health Care Service Plan, through its dispute resolution mechanism. If you disagree with the payor's dispute resolution response, you may submit a complaint through the Department's website.
What If I Have A Problem With A Medical Group?
You may report problems with a medical group using the methods described above, if the medical group is the payor. If you report a problem regarding a medical group, we will monitor the organization directly and through the health plans with which it contracts.
What Is The Department Doing To Resolve Some Of These Problems With Providers Not Getting Paid?
The Department is monitoring carefully all complaints submitted by providers regarding problems with health plans and payors. We look for patterns or systemic problems and address them with individual health plans or payors through a number of oversight tools, including financial audits and medical surveys. Additionally, we can and will take enforcement action against health plans found to violate the law. To date the Provider Complaint unit has recovered more than $20,000,000 in reimbursements for providers.
What Does the Review Process Consist of?
An Initial Review will be performed on all electronically filed provider complaints. This review will be based on the information provided within each complaint form filed. Data provided in these forms will be rigorously analyzed to look for evidence of payor "unfair payment patterns." It will also be used to identify prevalent types of payment or contract issues. This data will provide the basis of targeted Departmental follow-up investigations, and follow-up actions to eliminate the root cause of these problems.
A Case Review of provider complaints will be somewhat more limited, based on staff resources available, consistent with the Department’s priorities. This process will require a verification of the facts presented in an electronically filed complaint by comparing it with backup documentation. When substantive review of a complaint has been initiated, the Department will open a case file and will request the provider to submit backup documentation relative to the case. Upon receipt of the documentation, the Department will determine whether there is non-compliance with the provisions of the Knox-Keene Act, and its Regulations. In many instances, substantive review will make a determination of whether claims should have been paid, or whether interest is due. Trend analysis of the results of substantive review will also supplement the findings of the initial review process, to insure appropriate follow-up.
What Do I Need To Do To File A Complaint With The Department Of Managed Health Care?
Before you file a complaint with the Department of Managed Health Care, you should submit a request for dispute resolution through your payor's dispute mechanism. Then, if you disagree with the response, complete and submit a Provider Complaint Form with the Department.
Is This Complaint Process in Place of My Taking Legal Action?
The Department of Managed Health Care's complaint process does not take the place of a civil action. We cannot give legal advice or act as your attorney. The complaint process should not be considered a way to gather facts in preparation for any potential legal action. You can take legal action at any time during the complaint process. In the event that the claims comprising your complaint are in litigation the Department may, in its discretion, suspend or delay its investigation until after the civil adjudication of those claims.
What Qualifies as a "like" Multiple Complaint?
"Like" complaints are ones where the issues are the same or very similar. For "like" complaints, the Payor's actions giving rise to the complaints would be the same or very similar for each complaint. For Example:
- Payor fails to correctly pay claims for the same or very similar CPT codes or health care services;
- Payor fails to correctly pay interest on claims where interest is owed;
- Payor requests unnecessary documentation prior to paying claims for the same or very similar CPT codes or health care services;
- Payor violates the same provision of the applicable contract in regards to the payment of each claim;
- Payor is otherwise engaged in any other unjust payment pattern, such as those set forth in Title 28, California Code of Regulations section 1300.71 (a)(8)(A)-(T).
How Do I Determine if Our Entity is Considered a Risk-Bearing Organization?
A risk bearing organization is a professional medical corporation, other form of corporation controlled by physicians and surgeons, a medical partnership, a medical foundation exempt from licensure pursuant to subdivision (l) of Section 1206, or another lawfully organized group of physicians that delivers, furnishes, or otherwise arranges for or provides health care services, but does not include an individual or a health care service plan, and that does all of the following:
- Contracts directly with a health care service plan or arranges for health care services for the health care service plan's enrollees.
- Receives compensation for those services on any capitated or fixed periodic payment basis.
- Is responsible for the processing and payment of claims made by providers for services rendered by those providers on behalf of a health care service plan that are covered under the capitation or fixed periodic payment made by the plan to the risk-bearing organization.
As a Risk-Bearing Organization, am I Required to File Quarterly and Annual Financial Reports Under SB 260? When are These Reports Due to the DMHC?
Quarterly financial survey reports are due to the department not more than forty-five (45) days after the close of each quarter of the fiscal year.
Annual financial reports are due to the DMHC not more than one hundred fifty (150) days after the close of the organization's fiscal year beginning on or after January 1, 2005, and not more than one hundred fifty (150) days after the close of each of the organization's subsequent fiscal years.
Are There Different Reporting Requirements for Risk-Bearing Organizations That Have Less Than 10,000 Covered Lives?
Organizations serving less than 10,000 covered lives under all risk arrangements are required to file a Compliance Statement addressing the following: (1) A statement as to what percentage of completed claims the organization has timely reimbursed, contested, or denied during the quarter; (2) A statement as to whether or not the organization has estimated and documented it's liability for IBNR claims; (3) A statement as to whether or not the organization has at all times during the quarter maintained positive TNE; (4) A statement as to whether or not the organization has, at all times during the quarter, maintained a cash-to-claims ratio.
Regardless of the number of covered lives served under all risk arrangements, all risk bearing organizations are required to submit its annual financial survey report, not more than one hundred fifty (150) days after the close of the organization's fiscal year beginning on or after January 1, 2005, and not more than one hundred fifty (150) days after the close of each of the organization's subsequent fiscal years.
Are the Results of the Risk-Bearing Organizations' Financial Reports Available to the public?
Yes, within 120 days following each reporting period due date, the DMHC will make the following information available, on its website:
- A list of all risk-bearing organizations that have submitted substantially complete financial survey forms, if required, and whether the risk-bearing organization's submission reflects that the organization has met or not met each of the Grading Criteria.
- A list of all "non-compliant" organizations that fail to substantially comply with the reporting obligations.
- Comparative, aggregated data on all organizations, and information that enables consumers to assess an organization's relative financial viability.