SACRAMENTO, Calif. — Medical insurance company Blue Cross of California Partnership Plan was fined more than $1.2 million, Wednesday, after two Medi-Cal enrollees were denied coverage for a consultation for transgender-related procedures.
Blue Cross failed to authorize the coverage, in one case not until 200 days after the plan was legally required to authorize the service. The other enrollee had to wait 41 days. Both delays occurred even though an independent reviewer had determined the consultations were medically necessary.
Health plans are subject to a fine of no less than $5,000 for each day that Blue Cross lagged, prompting the California Department of Managed Health Care (DMHC) to take enforcement action to the tune of $1,205,000.
“The DMHC Help Center’s appeals process, called an Independent Medical Review (IMR), is a critical protection for health care enrollees," said acting director of the DMHC, Mary Watanabe. "The IMR is a backstop to ensure health plans cover medically necessary health care services enrollees are entitled to receive.”
According to a press release, Blue Cross acknowledged it failed to comply with the law and has agreed to pay the fine and complete a Corrective Action Plan to settle the issue. The plan has also updated their internal policies to ensure proper IMR handling in the future.
"It is a serious violation when a health plan fails to follow the Independent Medical Review decision and cover the required medical services," Watanabe said. "This mandated fine is needed to prevent similar violations from happening in the future.”
Any Californian enrolled in a health plan can file an IMR if their plan denies, changes, or delays a request for medical services, denies payment for emergency treatment, or refuses to cover experimental treatment for a serious condition.
If you are having trouble getting care, you can file a grievance with your health plan. If you do not agree with your health plan's response or the plan takes more than 30 days to fix the problem, you can file a complaint or apply for an IMR on the DMHC Help Center website or by calling 888-466-2219.
