!!!"#$#!%&!'(&)*+!,!'*-./0)*+ !'1%2/+3/456 !778 The Centers for Medicare and Medicaid Services has sanctioned two Medicare Advantage health plans headquartered in California, citing gross mismanage ment or misleading business and marketing practices. Woodland Hills-based Health Net and Oakland-based Arcadian Management Services have been suspended from soliciting new members for their Medicare Advantage and Part D pharmacy plans until corrective actions are taken and they prove to CMS the deciencies are not likely to occur. Health Net’s suspension went into effect on Nov. 19. Arcadian’s will begin on Dec. 5. Current enrollees will continue to receive coverage through the two plans. In the case of Health Net’s suspension, CMS ofcials decided against providing a standard 15-day interim period before its imposition. “The fear was that waiting could lead to health and safety issues,” said CMS spokesman Peter Ashkenaz. Ashkenaz noted that the de ciencies in Health Net’s management of its formulary for Medicare enrollees were so severe that they have been matched by only one other company, Arizona-based Fox Insurance Co. CMS terminated its Part D contract with Fox in March. Under pressure from state regulators, Fox surrendered its California insurance license last month, according to records on le with the Department of Managed Health Care. In a scathing letter sent to Health Net’s chief government programs ofcer Scott Kellyon Nov. 19, CMS ofcials outlined a series offailures regarding Health Net’s formulary for Medicare enrollees. Among them: • Enrollees were denied medications that CMS mandated should have uninterrupted access, such as anti-convulsant and AIDs drugs. • Quantity limits were imposed on drugs where no limitations should have been imposed. • Prescriptions were denied as not being part of Health Net’s formulary when they actually were. • Health Net failed to respond to redetermina tion requests (asking to reverse its decisions) in a timely manner. “Health Net has been wholly unable to satisfactorily address these serious deciencies and to deliver services in a manner consistent 9441(2!'*-:-;-*)+!8-4<)*)4=)6! 9/*>-*;! ?(**/-;;!@-;)26!7-+! 945)2)+A! B/22!)C>2-*)! ;3)!/++1)+!<(=/45!'*-:-;-*)+!/4!=-401=;/45! =-::14/;&!-1;*)(=3A !D$EFD$GEA 82/=H!@)*)!I-*!?-*)!J4<-*:(;/-4 K).)4;3! 9441(2! 9:)*/=(4!@)(2;3!8(*)! 8-45*)++A!@&(;;!L)5)4=&6!J*./4)A! 9! 0/+=1++/-4!-<!;3)!=3(22)45)+!<(=/45!+)4/-*! 3)(2;3=(*)!)C)=1;/.)+!/4!(!>-+;F*)<-*:! )4./*-4:)4;A!D$6"MEFD$6GMEA 82/=H!@)*)!I-*!?-*)!J4<-*:(;/-4 December 6-7 December 3-4 Calendar2 December 2010 December 7-8 I/<;3! 9441(2!N)3(./-*(2!@)(2;3=(*)! K&:>-+/1:A!O+;(4=/(!7(! P-22(!K>(6!7(! P-22(A! B/22!)C(:/4)!;3)!->>-*;14/;/)+!(40! =3(22)45)+!>*-./0)0!%&!3)(2;3=(*)!*)<-*:A! ! DQ"EFDEE#A 82/=H!@)*)!I-*!?-*)!J4<-*:(;/-4 E-Mail [email protected]with the details of your event, or call (877) 248-2360, ext. 3. It will be published in the Calendar section, space permitting. Continued on Next Page California Edition CMS Suspends Health Net, Arcadian Many Deficiencies in Medicare, Drug Plans Found CFO/COO COMPENSATION A PAYERS & PROVIDERS EXCLUSIVE WHITE PAPER COMPENSATION ON NEARLY 200 OF CALIFORNIA ’ s HEALTHCARE CFOs & COOs NOW AVAILABLE Report is $149. Report and Salary Data is $275. Call (877) 248-2360, ext. 2 OR CLICK HERE to Order
Transcript
8/8/2019 Payers & Providers – Issue of December 2, 2010
The Centers for Medicare and MedicaidServices has sanctioned two MedicareAdvantage health plans headquartered inCalifornia, citing gross mismanagement or
misleading business and marketing practices.Woodland Hills-based Health Net and
Oakland-based Arcadian ManagementServices have been suspended from solicitingnew members for their Medicare Advantageand Part D pharmacy plans until correctiveactions are taken and they prove to CMS thedeciencies are not likely to occur. HealthNet’s suspension went into effect on Nov. 19.Arcadian’s will begin on Dec. 5. Currentenrollees will continue to receive coveragethrough the two plans.
In the case of Health Net’s suspension,CMS of cials decided against providing a
standard 15-day interim period before itsimposition. “The fear was that waiting couldlead to health and safety issues,” said CMSspokesman Peter Ashkenaz.
Ashkenaz noted that the deciencies inHealth Net’s management of its formulary forMedicare enrollees were so severe that theyhave been matched by only one othercompany, Arizona-based Fox Insurance Co. CMS terminated its Part D contract with Fox inMarch. Under pressure from state regulators,
Fox surrendered its California insurancelicense last month, according to records onle with the Department of Managed HealthCare.
In a scathing letter sent to Health Net’schief government programs of cer Scott Kelly on Nov. 19, CMS of cials outlined a series of failures regarding Health Net’s formulary forMedicare enrollees. Among them:
• Enrollees were denied medications thatCMS mandated should have uninterruptedaccess, such as anti-convulsant and AIDsdrugs.
• Quantity limits were imposed on drugswhere no limitations should have beenimposed.
• Prescriptions were denied as not being
part of Health Net’s formulary when theyactually were.
• Health Net failed to respond toredetermination requests (asking to reverseits decisions) in a timely manner.
“Health Net has been wholly unable tosatisfactorily address these serious decienciesand to deliver services in a manner consistent
Kaiser Permanente granted $10.5million to beneficiaries near its
Oakland headquarters late lastmonth, including $7.5 million toOakland schools to support school-based health clinics.
“These grants are expresslytailored to address importantcommunity health needs in thiscity. By focusing specifically onprograms that serve schoolchildren,the grants represent hope for thefuture by giving youth the tools anddirection they need to thrive,” saidGregory A. Adams, president of Kaiser’s Northern Californiadivision.
Along with the school grants,which will also be used to help the
district’s African-American malescomplete their education, Kaiseralso granted $1 million to theOakland Police Department tosupport violence prevention andyouth mentoring programs, and $2million to Remember Them, aneducational foundation that teacheschildren about 25 internationalhumanitarians.
“It’s tremendously encouragingto see Kaiser Permanente extend itsleadership position on this issueand model the type of public-private partnership needed torealize our vision for OUSD,” saidOakland Unified School District
Superintendent Tony Smith.
PPOs Get MiddlingScore on Report Card
California’s preferred providerorganizations have significant roomfor improvement, based on theirsecond annual report card scoresissued by the state Department of Insurance.
Continued on Page 3
NEWS
Suspensions (Continued from Page One)
with its obligations to CMS and to theMedicare beneciaries,” the letter said.
Health Net had been issued 36 notices of
non-compliance with CMS regulations andthree warning letters between January andSeptember of this year, and had beenpreviously restricted from receiving enrolleesreassigned from other health plans. It hadbeen briey suspended from marketing andenrolling new Medicare beneciaries in 2008due to similar troubles.
“We are working closely with CMS toresolve these matters as quickly as possible.We hope in the next months we candemonstrate to CMS that we havesuccessfully addressed the issues they haveraised,” said Health Net Chief Executive
Of cer Jay Gellert in a prepared statement.Health Net of cials did not respond to arequest for further comment.
In Arcadian’s case, the plan was accusedof allowing its agents to engage in unethicaland deceptive behavior to recruit newenrollees. It had been under CMS scrutinysince 2008.
Among the abusive practices cited bythe agency was enrolling individuals inArcadian plans without their consent;claiming Arcadian’s products were connectedto national healthcare reform; and makingdirect contact with prospective enrollees at
their homes or through cold calling. Theseviolations either came from consumer
complaints veried by CMS or as the result of CMS’s “secret shoppers” attending Arcadianmarketing events.
In October 2009, Arcadian received aformal warning from the agency to reform itsmarketing practices. However, the volume of consumer complaints CMS received between January and August this year regardingmisrepresentations involving Arcadian wasanywhere from double to 3.5 times thenational average.
In one instance, a cancer patient misledinto enrolling missed weeks of chemotherapy.In another case, a disabled minor was enrolledafter false assurances were made to her fatherThe enrollee subsequently had her anti-seizuremedication cut off, leading to an 18-day
hospitalization that resulted in her developingpressure ulcers.
“This is horrifying,” said Judy Dugan,research director for Consumer Watchdog, aSanta Monica-based consumer advocacyorganization that monitors health plans. “Theyare preying on the poor and disabled forprot. Both plans essentially put lives at risk.”
An Arcadian spokeswoman declined tocomment directly on the suspension andallegations, but did provide what she termed“approved talking points” via e-mail.
“Our goal is to work closely with CMS tomeet or exceed their expectations as well as
the expectations of our members,” said thefourth and nal point.
DMHC Fines Plans $4.85 MillionAction Taken to Stop Inaccurate Claims Payments
The California Department of ManagedHealth Care has levied nes totaling $4.85million against most of the state’s majorhealth plans, claiming they failed toaccurately pay hospitals and physicians forcare provided.
At a Tuesday press conference, DMHCof cials outlined how seven plans – AnthemBlue Cross of California, Blue Shield of California, Kaiser Foundation Health Plan,Cigna, Aetna, Health Net andUnitedHealthcare/PaciCare – failed to paymany claims led by hospitals and medicalgroups. The nes were the largest ever leviedfor such violations, according to DMHCdirector Cindy Ehnes.
Health plans have a statutory obligation
to pay 95% of claims within 30 to 45 days of receipt. However, audits of the plansconducted between June 2008 and Septembe2009 indicated that payment compliance wasas low as 75%.
Moreover, when providers appealedrejected claims, ve of the seven insurersmerely routed the appeals right back to thesame department or individual who rejectedthe initial claim.
“There was no real reconsideration of theclaim, which made the process essentiallyuseless,” Ehnes said, later referring to aprovider’s gripe that a claim was merely a“ticket for chasing payment.”
Continued on Next Page
8/8/2019 Payers & Providers – Issue of December 2, 2010
None of the six PPOssurveyed received the highest scoreof four stars in any of the ninecategories where a star ratingapplied. Aetna, Cigna andUnitedHealthcare each receivedthree stars for overall quality of care provided. Blue Cross of
California, Blue Shield of California and Health Net eachreceived two stars.
"I am grateful for theircooperation, but this report cardshows they will have to do better.This should be their wake-up call,"said Insurance Commissioner StevePoizner, who noted the plansranked in “the middle of the pack”when stacked up against plansfrom other parts of the country.
The report card featured a newcategory for 2010: customersatisfaction. Only Aetna scoredhigher than a single star. For thecategory of easily obtaining care,
only UnitedHealthcare received athree-star rating.
Altogether, the plans wererated in 48 categories. They scoredbest in some preventativecategories, such as pediatricasthma care and testing forcholesterol levels among diabeticpatients.
San GorgonioMemorial Hospital
Changes ManagementFirm
Facing a $3 million annualoperating deficit, the board of directors of San GorgonioMemorial Hospital voted lastmonth to terminate its managementcontract with Brentwood, Tenn.-based HealthTech ManagementServices. It entered into a 10-yearmanagement pact on Nov. 18 witha local firm, Redlands-based EpicManagement, LLP.
Epic retained San GorgonioChief Executive Officer MarkTurner and Chief Financial OfficerDavid Recupero.
Job Does Not Guarantee CoverageUCLA Says Many Have Work, But Lack Insurance
Despite the common wisdom that a jobmeans employer-sponsored health insurance,a new study suggests that there is a largedisconnect between the two in California.
According to the UCLA Center forHealth Policy Research, 5.7 million of theGolden State’s residents lack healthinsurance, even though they live in ahousehold with at least one employed familymember. That represents 20% of thepopulation under the age of 65, and 15% of California’spopulation as a whole. Many of those without coverage were poor or Latino.
“The number of uninsured working
people revealed by this study is a furtherexample of how the healthcare system in
California is broken,” said Robert K. Ross,M.D., chief executive of cer of The CaliforniEndowment. It jointly funded the study withthe California Wellness Foundation.
Southern California was home to the largmajority of those who lacked insurance –more than 57% of the total. Nearly 32% of those live in Los Angeles County.
The study’s data was gleaned from asurvey conducted in 2007, prior to the GreatRecession and a further erosion of employment-based healthcare benets.
The study’s auhtors suggested that therollout of the Patient Protection and
Affordable Care Act may lower the numbersof unisured with jobs over time.
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Fines (Continued from Page Two)
In addition to the nes, which rangedfrom $300,000 to $900,000 per plan, theplans are required to pay all legitimateclaims and interest within 180 days. Ehnes
said this amount would run into the tens of millions of dollars. They must also submitcorrective actions to the agency.
The agency’s auditors examined arelatively small cross-section of randomlyselected claims from each insurer, rangingfrom 200 to 1,000 apiece. However, Ehnesnoted the plans agreed that the sampleswere representative enough to demonstratethat such violations were widespread.
The nes came just weeks after theDMHC levied a $1.62 million penaltyagainst Blue Cross for not paying stop-lossclaims to hospitals for long patient stays.
The agency was also blasted byAssemblyman Dave Jones, D-Sacramento,for not sending representatives to anoversight subcommittee hearing last monthinvestigating shorted insurer payments foremergency room care. Jones won election as
California Insurance Commissioner and willbe sworn into of ce next month.
DMHC of cials claimed they were notprepared to attend the hearing, according to
the publication California HealthLine.Ehnes said her agency began examining
claims issues more closely after the stateSupreme Court banned providers fromengaging in the balance billing of ER patientslast year
Although the California MedicalAssociation supported the DMHC, itspresident, James Hinsdale, M.D., called thenes “chump change that amount to littlemore than a slap on the wrist for highlyprotable health plans that systematicallydeny legitimate claims and routinely block,delay or limit physician reimbursements as
one tactic to boost their bottom lines.”Ehnes conceded that the nes were
relatively small, but that the DMHC’s actionswould still hold sway.
“Public exposure, nes and correctiveaction will help change things,” she said.
In November 2010, the Centers forMedicare and Medicaid Services approvedCalifornia’s five-year Section 1115Medicaid waiver proposal.!Through thewaiver, California will receiveapproximately $10 billion in federal fundsto improve care delivery and support thestate’s preparation for the requirements of federal healthcare reform.
The largest part of the waiver – and theone most immediately pressing to Medi-Caldoctors and other healthcare providers –makes the transition of seniors and people
with disabilities (SPDs) from fee-for service Medi-Cal intomanaged care mandatory. Theintent is to cut costs whilebetter coordinating care.
The State is planning to startenrolling SPDs into managedcare on June 1, 2011, with thetransition spread over a 12-month period.!This affectsapproximately 170,000 peoplein Los Angeles County, and morethan 400,000 statewide.
While many healthcare experts
believe this transition will helpimprove healthcare quality while alsocontaining costs, others areconcerned that health plans won’teffectively meet the needs of the SPDpopulation.
Because of their often complex andmultiple health conditions, SPDs tend touse a vastly outsized share of Medi-Calfunding. Although SPDs just 10% of theMedi-Cal population, they absorb 75% of total Medi-Cal expenditures, according tothe California Foundation for IndependentLiving Centers.
If done right, an organized, coordinatedsystem can provide better care than thecurrent fragmented, coordinate-it-yourself system that currently serves most SPDs.
However, we shouldn’t gloss over thechallenges we face to effectively meet thehealthcare needs of this vulnerablepopulation.
One of the most significant challengesis finding providers willing to accept Medi-Cal reimbursement. This will continue tobe a challenge for Medi-Cal health plans aswe expand our provider networks to
include the doctors and hospitals who alreserve the SPD population in fee-for-servicMedi-Cal.
Another challenge we face is thefragmentation of our healthcare system. Fexample, the SPD population faces signifibehavioral health issues, but behavioralhealth services are carved-out of Medi-Camanaged care. This means, if we truly wanhelp our SPD members, we must develop maintain strong partnerships with our locacounty agencies and communityorganizations that provide behavioral hea
services. Health plans will aneed strong care coordinatioand partnerships with socialservice agencies that serve SA third challenge will be proto seniors and people withdisabilities and their advocatthat moving into Medi-Calmanaged care will ultimatelybenefit them. In the fee-for-service model, care is
fragmented. Patients need to ftheir own doctors, and there is no to help them navigate the system.
When done right, managed care ocare coordination and casemanagement, health navigators, a
member services helpline, a nurse advicehotline, and transportation aid.
Additionally, healthcare experts believmanaged care can help the Medi-Cal proguse public resources more effectively.As aMedi-Cal managed care plan, L.A. CareHealth Plan recognizes the challenges ahebut we are ready to meet these challengesorder to improve care for this vulnerablepopulation.
The hard work has already begun, but
there is still much more to do. It will take efforts of all parties to transition thisvulnerable population into managed care.
OPINION
Making The Medi-Cal Waiver WorkBiggest Challenge is Caring For Seniors & Disabled
MEDICARE COMPLIANCE ADVISOR - ensures that L.A. Care and its subcontracted provider network is compliant with all Centerfor Medicare &!Medicaid federal regulatory requirements. This is achieved by participating in the annual PPG and quarterly auditsworking with internal and external staff to correct performance deciencies, identifying internal areas for improvement, serving athe compliance contact with Plan Partners for member grievance oversight, provider services oversight, and interpreting CMS/SNPProgram requirements for L.A. Care. !Additionally, this individual is a resource to internal staff on compliance matters relating toCMS/SNP standards, including, but not limited to, marketing materials, grievances and appeals, member rights issues, and claimsadjudication.! Responsible for performing internal audits, monitoring for implementation of corrective measures, and interpretationof CMS requirements. !Working knowledge of federal and state requirements is required, as well as highly developed analytical skill
and excellent verbal and written communication skills.!For complete job description, qualications/requirements, visit our website: www.lacare.org
To apply, email resume with salary history and requirement to: [email protected] referencing “Payers & Providers Ad”
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