Friday, April 25, 2025
DMHC Fines Kaiser Permanente $819,500 for Failing to Quickly Handle Member Complaints
(Sacramento) – The California Department of Managed Health Care (DMHC) fined Kaiser Foundation Health Plan, Inc. (Kaiser Permanente) $819,500 for failing to handle health plan member complaints, also called grievances or appeals, in a timely manner.
“Complaints are an important health care right to ensure members receive the care they need,” said DMHC Director Mary Watanabe. “Health plans are required by law to have a grievance and appeal system to resolve member complaints, including providing timely notice of the plan’s decision in response to member complaints, in addition to providing information about how to appeal the plan’s decision. Actions like today’s fine keep the system working for patients.”
MEMBER PROTECTIONS: Health plans are required to have a grievance and appeal system to timely review, resolve and respond to member complaints in an appropriate manner. California law requires health plans to acknowledge receipt of a standard grievance within five calendar days, resolve the grievance within 30 days, and send a written resolution to the member. Plans must also inform members of their appeal rights, including the right to file an appeal with the DMHC if they do not agree with their health plan’s resolution of their complaint.
ENFORCEMENT ACTIONS: The DMHC Help Center referred several member complaints to the Department’s Office of Enforcement for further investigation, which found Kaiser Permanente failed to timely process a total of 61 complaints. This included failure to timely provide the written acknowledgment of the receipt of the grievance within five calendar days in 14 cases, and failure to timely respond to the member’s standard grievance within 30 calendar days of receipt of the grievance in 54 cases. The $819,500 fine is the total of the following enforcement actions involving 61 cases:
- Enforcement action 23-045 with a $263,000 administrative penalty for 21 cases
- Enforcement action 22-661 with a $301,500 administrative penalty for 20 cases
- Enforcement action 21-826 with a $255,000 administrative penalty for 20 cases
WHAT MEMBERS CAN DO: The DMHC encourages health plan members experiencing issues with their health plan to first file a complaint, sometimes called a grievance or appeal, with their health plan. Common issues include getting timely access to care, receiving an inappropriate charge or bill, or a denial or delay in care or treatment. If the member does not agree with their health plan's response to their complaint or the plan takes more than 30 days to fix the problem for non-urgent issues, the member can contact the DMHC Help Center. The DMHC Help Center will work with the member and health plan to resolve the issue. If the health plan member has an urgent grievance, they do not need to file with their health plan first. A health plan member with an urgent grievance can file directly with the DMHC Help Center.
If a health plan denies, changes or delays a request for health care treatment or services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment, a health plan member can apply for an Independent Medical Review (IMR) through the DMHC Help Center. Independent providers will review the case, and the health plan must follow the IMR determination.
For more information about how to file a complaint with the DMHC, or apply for an IMR, please visit the DMHC website at www.DMHC.ca.gov.
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About DMHC:
The DMHC protects the health care rights of more than 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.9 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.DMHC.ca.gov or call 1-888-466-2219.