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Friday, April 29, 2011

 

Kern Health Systems request for lower standards to provide timely care to patients denied

Plan requested exemption from first law in nation to shorten patient wait times

(Sacramento) – The California Department of Managed Health Care (DMHC) has rejected a Kern Health Systems request to use time-elapsed standards that are not as strict as new state regulations that went into effect this year to provide predictable wait times for appointments. On January 17, 2011, the DMHC timely access regulations went into effect, making California the first state in the nation to provide patients with predictable wait times. Kern Health Systems was the only one of the 125 plans in the state, including those also serving Medi-Cal and other government-funded programs, to request alternatives to the standards.

“California law now requires all health plans to provide health care appointments within specified time frames,” said DMHC Interim Director Edward G. Heidig. “The alternate standards requested by Kern Health Systems were unrealistic, did not comply with the spirit of the law, and ultimately could have put patients at risk.”

Under the timely access regulations, plans must offer non-urgent primary care appointments within ten business days, and appointments with specialists within 15 business days. Kern Health Systems requested alternate standards of non-urgent primary care appointments within 20 business days, and appointments with specialists between 30-60 business days, including critical specialty services such as treatment for neurological and orthopedic conditions.

After thorough review and attempts to work with the health plan, the DMHC denied the request for alternate time-elapsed standards because the requested wait times were excessive and based on unreliable data submitted by the plan about its ability to contract with necessary specialists. The plan has 30 days to either request an administrative hearing or file new information with the DMHC on how it will comply with the standards in the regulation.

The regulation requires that if timely appointments are not available in geographic areas with provider shortages, a health plan must refer enrollees to available and accessible contracted providers in neighboring service areas. A health plan must also ensure that it has contracts with a sufficient number of doctors in each geographic area to serve its members. This means that plans must have a strong and varied provider network so that appointments can be made within the specified timeframes.

The DMHC is also cooperating with an audit called for earlier this year by Senator Michael Rubio (D-Bakersfield) of the high reserve account currently held by Kern Health Systems. According to financial statements filed by the plan with the DMHC, the plan currently has a reserve of $70 million more than the mandated amount. The California State Auditor will be conducting the independent audit over the next several months and will issue a public report once the analysis is completed.

Consumers or providers who have questions or concerns about timely access to care or other health care issues are urged to contact the DMHC’s Help Center at 1-888-466-2219, or online at www.healthhelp.ca.gov.

The California Department of Managed Health Care is the only stand-alone HMO watchdog agency in the nation, touching the lives of more than 21 million enrollees. The DMHC has helped more than a million Californians resolve their health plan problems through its Help Center. The Department educates consumers on health care rights and responsibilities, and works closely with health plans to ensure a solvent and stable managed health care system. 

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