Friday, June 17, 2022
DMHC Fines Molina $1 Million in Enforcement Actions for Delaying Provider Payments
Molina Healthcare of California Remediated $82.2 Million in Payments and Interest to Providers
(Sacramento) – The California Department of Managed Health Care (DMHC) today announced enforcement actions against Molina Healthcare of California (Molina) including a $1 million fine for the plan’s failure to timely acknowledge and resolve 29,124 provider disputes between September 2017 and September 2018. The plan has paid the fine and implemented corrective actions, including the remediation of $80.3 million in payments to providers, with an additional $1.8 million in interest.
“It is important health plans promptly and accurately pay claims to hospitals, doctors and other providers when health care services are provided to enrollees to ensure the financial stability of providers, and the overall stability of the health care delivery system,” said DMHC Director Mary Watanabe. “Molina’s systemic failures to timely resolve provider disputes caused payment delays, potentially jeopardizing the financial stability of providers. The plan has agreed to take corrective actions including remediating payments to impacted providers plus interest."
Health plans are required to have a Provider Dispute Resolution (PDR) program when a dispute arises over payments to providers. California law requires a health plan to identify and acknowledge each provider dispute within two working days of the date of receipt of an electronic provider dispute, and 15 working days of the date of receipt of a paper provider dispute. Additionally, health plans must resolve each provider dispute or amended provider dispute and issue a written determination stating the pertinent facts and explaining the reasons for the plan’s determination within 45 working days after the date of receipt.
As part of the required corrective actions, and in addition to remediating payments to providers, the plan will be required to report information to the DMHC to demonstrate compliance with acknowledgment and resolution timeliness requirements regarding provider disputes.
If a provider has gone through a plan’s PDR program and does not agree with the plan’s determination, or the plan takes longer than 45 days to issue a written determination, the provider can contact the DMHC Help Center’s Provider Complaint Unit for further assistance.
The Provider Complaint Unit administers the Independent Dispute Resolution Process (IDRP) that allows providers or health plans to dispute whether a payment in certain circumstances from a DMHC-regulated plan was appropriate. If the payment qualifies for the IDRP, an external reviewer goes over the claim and determines the justified rate.
The DMHC performs analyses on unfair payment patterns and emerging trends on all provider complaints. The Department uses this information to help identify criteria for audits of health plans and their delegated entities. The DMHC initiated an investigation following the receipt of over 100 provider complaints suggesting Molina’s failure to timely acknowledge receipt of and failure to timely issue written determinations in response to provider disputes. The Provider Complaint page on the DMHC website provides more information on how to file for an IDRP with the Department.
About DMHC:
The DMHC protects the health care rights of more than 27.7 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.5 million Californians to resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.HealthHelp.ca.gov or call 1-888-466-2219.