Dear Provider Members,
Our office has been actively pursuing the resolution of claims on your behalf for post-stabilization care we believe have been improperly denied by health care plans. We have escalated our concerns to the DMHC and wanted to share our findings with you.
In recent discussions with the DMHC, we have been advised that contact made to the patient’s health care service plan, or the health plan’s contracting medical provider, for authorization to provide post-stabilization care, must fulfill two requirements:
1. Requests for authorization to provide post-stabilization care must be made by a telephone call, and
2. The telephone call requesting authorization must be made:
a. Per the instructions on the patient’s health plan member card, or
b. Using the specific contact information provided to the hospital by the health care service plan.
The DMHC has also advised us that contacting the health plan, or its contracting medical provider, in some other way (via email, fax, or a different phone number) will not trigger the requirement for the plan to respond within 30 minutes and will not trigger the plan’s obligation to cover post-stabilization care or transfer of the patient.
We strongly disagree with the requirements above and have challenged the DMHC to provide further guidance. Our position is the obligation to pay is triggered upon notification to the health plan or its contracting medical provider, regardless of the form of notification used (via phone call, fax, e-portal, or email). In support of our position, we have provided the DMHC with Health Net’s Medi-Cal Operations Guide stating, due to the COVID-19 State of Emergency, the phone number used to notify the plan of inpatient admission has been temporarily suspended, and to use fax instead.
The DMHC has responded stating they will create an All Plan Letter (APL) to provide clarity to health plans regarding their post-stabilization obligations, as well as update the DMHC website where health plans provide their current contact information. We will provide you with an update as soon as this information is received.
In order to enforce violations for failure to respond timely to a request for authorization of post-stabilization services, the DMHC has requested providers document the following notes in their hospital records:
1. When the patient was stabilized.
2. The telephone call requesting authorization for post-stabilization services, with the following information:
- When the call was made.
- What number was called.
- Who you spoke with including:
- The name of the representative.
- The call reference number.
- What service was requested:
- Must document you are requesting authorization for inpatient admission.
- Phone calls made to determine patient eligibility or verify insurance are not a request for authorization and are insufficient to trigger the plan’s requirement to respond within 30 minutes.
3. The response, or lack thereof, by the plan or its contracting medical provider.
If no other means of initial contact (via fax, e-portal, etc.) are delineated by a provider manual or contract, we suggest that you notify the plans by telephone call for authorization requests to provide post-stabilization care, and document the call per the DMHC guidance above.
If a contract exists between you and the health plan, and the plan requires notification by a method other than telephone call, we suggest that you document this in your hospital records. For example, you may add a note stating the request for authorization of post-stabilization services was faxed to the plan per a specific section of the provider manual, or as instructed per a specific section of the contract (e.g. On (DATE), a facesheet of admission and request for authorization was faxed to 123-456-7890 per section ___ of the contract).
Please be advised that we recommend you confer with your internal legal counsel prior to making any changes to how you notify the plans for authorization requests or how you document those requests.
While we await further updates, we will continue to advocate for your rights to ensure health plans are held financially responsible for the health care services you provide. Our office is presently challenging the DMHC to resolve claims for care rendered to patients during the COVID-19 Public Health Emergency (PHE) period declared by the Department of Health & Human Services between January 31, 2020 and May 11, 2023. During the pandemic, the DMHC directed plans to take immediate steps to reduce or remove unnecessary barriers to the efficient admission, transfer, and/or discharge of health plan enrollees. Reducing and removing such barriers were to allow hospitals to quickly respond to the unfolding crisis as shown and described below:
The DMHC expects plans to take steps to reduce or remove administrative barriers on hospitals during this time. As such, pursuant to the authority granted by California Executive Order N-80-20, issued on September 23, 2020, the DMHC directs plans to file by December 29, 2020 and again by January 12, 2021, a narrative description of the steps the plan has taken and also what steps the plan will to take to reduce or remove unnecessary administrative barriers with respect to hospitals. Such steps may include, but are not limited to:
- Increasing the number of health plan staff available to respond to hospitals’ requests to admit, transfer or discharge plan enrollees.
- Increasing the number of health plan staff available to respond to hospital requests during non-business hours.
- Working with durable medical equipment suppliers, pharmacies, and other suppliers to ensure they are available to quickly provide needed equipment, medications, and services to plan enrollees who are being discharged from a hospital.
- Waiving prior authorization requirements or providing blanket pre-authorizations in certain circumstances, such as inpatient admissions.
However, it appears this did not happen, and we intend to hold the DMHC and the plans financially responsible for their failures.
Please let us know if you have any questions regarding the DMHC notification and documentation requirements above, or if you have any concerns regarding unresolved claims for services rendered during the COVID-19 PHE.
If you are outside of California, please check your state laws for any authorization waivers enacted during the COVID-19 PHE. Should you need assistance using those waivers to overturn claims for services rendered during the pandemic, please reach out to our office to discuss possible representation.
Compliance Auditor II
Categorised in: Press Releases
This post was written by ernncra