March 06, 2017
Area(s) of Interest: Health Care Reform Licensing & Regulatory Issues
Ninety percent of health plans' 2015 timely access compliance reports submitted to the California Department of Managed Health Care (DMHC) contained one or more significant data inaccuracies, making it virtually impossible for the agency to measure health plan compliance.
California's timely access regulations require plans to maintain provider networks sufficient to ensure that consumers can get appointments within defined timeframes. To ensure that these appointment timeframes are met on a consistent basis, each health plan must monitor its own network, measure appointment availability and submit compliance reports to DMHC every year.
According to DMHC, 36 of 40 health insurers reviewed could face fines for failing to submit accurate data or comply with state rules.
DMHC said that while some data errors can be attributed to a lack of attention to detail or a failure to accurately perform basic mathematical calculations, several of the issues involve failure by health plans to follow the mandatory DMHC methodology, as required by law.
“Other significant data errors appear to have been caused by work performed by a single vendor hired by numerous health plans to gather data and prepare compliance reports. Twenty-two health plans that used this vendor submitted deficient compliance reports, several of which included information concerning thousands of primary care physicians and specialists who were not under contract with the health plan and who did not participate in the plan’s network.”
DMHC found the errors submitted by the vendor so egregious that it banned the plans from using the vendor and will require plans to use a DMHC-approved vendor moving forward.
Some of the faulty data health plans submitted included using the names of physicians that were not a part of the plan at all. For example, Aetna Health of California, Inc., greatly overinflated its reported specialist network by submitting the names of 30,000 cardiologists, dermatologists and allergists — three times higher than the number of specialists reported by any other health plan for those three provider types.
Fourteen plans also made simple mathematic calculation errors, requiring DMHC to spend significant time and resources to audit and correct data. “Errors of this type strongly suggest that health plans did not allocate the resources necessary to ensure appropriate report review and submission of accurate data, data for which they are required to attest accuracy under penalty of perjury," the report said.
According to DMHC, the serious and significant failure by California’s health plan industry to ensure gathering and submission of accurate timely access compliance data has forced the agency to take steps to protect California consumers and ensure access to care as required under the law.
“California’s health plan industry must immediately secure all resources necessary to gather data in accordance with the mandatory DMHC methodology and accurately report compliance in all future reports. Plans that do not comply will be subject to enforcement action,” the report said.
In an effort to gain better compliance with agency requirements, DMHC held an all-stakeholder meeting last month to discuss steps that must be taken by health plans to ensure that the 2016 compliance data—due to be submitted in March 2017—is validated and accurate.
Only four health plans submitted information without identifiable errors. Two were full-service health plans, Community Health Group and Inland Empire Health Plan. The two others specialize in behavioral health: Human Affairs International of California and Managed Health Network.
Click here to read the DMHC report.