July 06, 2018
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Practice Management
The California Medical Association (CMA) has learned that two health plans, the Inland Empire Health Plan (IEHP) and Molina Healthcare, are terminating their contracts with Vantage Medical Group. Two other plans, Blue Shield of California and Care1st Health Plan, have issued notices of material breach with an intent to terminate. The plans have filed requests with the California Department of Managed Health Care (DMHC) to transfer their enrollees to other delegated groups.
According to IEHP’s block transfer filing with DMHC, Vantage engaged in conduct that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP’s Medi-Cal managed care enrollees. According to IEHP, Vantage had, over a period of years, engaged in conduct that violates state and federal laws regarding the prompt and timely payment of provider claims, includes manipulating and falsifying claims, banking records and audit reports.
The plan filings with DMHC indicate over 280,000 enrollees will be affected by the IEHP and Molina terminations as follows:
- Inland Empire Health Plan: Termination effective August 31, 2018, affecting 171,425 enrollees in Riverside County and 102,621 enrollees in San Bernardino County.
- Molina Healthcare: Termination effective August 31, 2018, affecting 7,413 enrollees.
Blue Shield and Care1st issued notices of their intent to terminate, if Vantage fails to correct the breaches. If the breaches are not corrected to the payors’ satisfaction, another 6,000 enrollees will be affected as follows:
- Blue Shield of California: Termination effective August 31, 2018, affecting 2,979 enrollees.
- Care 1st Health Plan: Termination effective August 31, 2018, affecting 3,034 enrollees.
CMA will provide additional information on the transitions as it becomes available. Physicians should be diligent in obtaining updated insurance information from patients and verifying eligibility at the time of scheduling, if possible, to avoid unnecessary patient confusion and denials of payment for services rendered.
Patients may also be able to continue to see their physicians, even if they are not contracted with the patient’s new delegated entity, under California’s continuity of care law. Under continuity of care laws, patients with an acute condition, serious chronic condition, duration of a pregnancy, duration of a terminal illness, care of children between birth and 36 months, or for the performance of a surgery or other procedure that has been authorized, may qualify to request continuity of care. To request continuity of care, patients should call the health plan number on the back of their ID cards.
For more information on continuity of care requirements, see CMA On-Call document #7051, “Contract Termination By Physicians and Continuity of Care Provisions.”
CMA will provide more information on IEHP’s transition once we received updated information on the receiving groups. Practices that are experiencing problems with Vantage or issues resulting from the plan terminations are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or firstname.lastname@example.org.