FOR IMMEDIATE RELEASE: NON-PANELED CCS DENIALS

December 29, 2014 1:00 pm – Published by

Cypress, CA, December 29, 2014 – Through our regulatory representation and continuous monitoring for rising trends, it has become apparent that over the last couple of years, Medi-Cal Managed Care Plans have been denying claims they determine to be the financial responsibility of California Children’s Services (CCS) and denying said claims because the provider is “non-paneled.” Said denials continue to exacerbate an already fragile and burdened health care delivery system. Moreover, these non-paneled CCS denials contravene existing California Law.

CCS provides medical care, equipment, and rehabilitation for children with serious medical conditions throughout the state. CCS has provided needed services for many beneficiaries in California, however, the division of care and payment between CCS and Medi-Cal Managed Care Plans has created issues.

Title 22 of California Code of Regulations §51002(a) states:

A provider of service under the Medi-Cal program shall not submit claims or demand or otherwise collect reimbursement from a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary for any service included in the Medi-Cal’s program’s scope of benefits in addition to a claim submitted to the Medi-Cal program for that service…

As a direct result of Medi-Cal Managed Care Plans’ disregard for their obligations and responsibilities, CCS beneficiaries have been billed for emergency services rendered to them when the provider was not CCS-paneled.

Moreover, through our regulatory representation, we have seen numerous cases where:

(1) A patient presents to a hospital’s emergency department for medically necessary treatment.

(2) The patient requires post-stabilization services.

(3) The hospital contacts the Medi-Cal Managed Care Plan for authorization for post-stabilization treatment and care pursuant to Health and Safety Code §1262.8(b)(2).

(4) The Medi-Cal Managed Care Plan authorizes post-stabilization treatment and care pursuant to Health and Safety Codes §1262.8(d)(1)(A) and/or (d)(2).

(5) The hospital relies upon the Medi-Cal Managed Care Plan’s authorization and renders post-stabilization treatment and care to their own detriment.

(6) The hospital submits its claim to the Medi-Cal Managed Care Plan.

(7) The Medi-Cal Managed Care Plan denies the claim as per CCS carve out/non-paneled provider.

90% of CCS enrollees have Medi-Cal coverage. According to the Stanford Center for Policy, Outcomes and Prevention CCS Administrative Data, 49% of CCS enrollees have more than 1 emergency department visit per year.

The division of care and payment between CCS and Medi-Cal Managed Care Plans has ultimately posed challenges by:

  • Delaying care for children with chronic medical conditions
  • Fragmentizing coordination of care
  • Increasing costs to the state

Our investigation in this matter has revealed that Medi-Cal Managed Care Plans have disregarded the fact that CCS can receive requests for authorization of acute emergency services from physician providers and hospital facilities that do not have CCS approval, but may be the nearest facility or provider to the client. (Department of Health Care Services Numbered Letter No. 10-0806).

Additionally, our communications with Dr. Edward Bloch of the Los Angeles County CCS office has shed light on this issue as he has provided guidance on Medi-Cal Managed Care Plans’ responsibilities with regards to notifying providers when a patient has a pre-existing CCS eligible condition, and Medi-Cal Managed Care Plan’s responsibilities with regards to referring patients if they are believed to have a high likelihood of meeting CCS medical eligibility criteria.

Moreover, since 2012, the Department of Managed Care has communicated with us their concerns over the growing amount of cases they are seeing where Medi-Cal Managed Care Plans issue authorization, subsequently deny the claim and refuse to pay for the CCS condition services, and CCS likewise denies payment because the provider is not paneled. We are currently working with the Department of Managed Care to provide and establish a concrete system to properly address these claims.

We are also currently working with the Department of Health Care Services, and have requested the issuance of a numbered letter to be published that will:

  1. Notify Medi-Cal Managed Care Plans of their responsibility to notify providers when a patient has a pre-existing CCS eligible condition/is a CCS enrollee.
  2. Clarify that a provider’s responsibility to seek CCS authorization and/or arrange for the transfer of the patient to a CCS approved hospital is not triggered until the Medi-Cal Managed Care Plan notifies the provider that the patient has a pre-existing CCS eligible condition.
  3. Clarify that if the Medi-Cal Managed Care Plan fails to notify providers that a patient has a pre-existing CCS eligible condition/is a CCS enrollee, the Plan will continue to be responsible for providing medical care and case management.
  4. Clarify that Medi-Cal Managed Care Plans’ responsibilities of referring patients to CCS if they are believed to have a high likelihood of meeting CCS medical eligibility criteria

Additionally, the Department of Health Care Services has initiated a stakeholder process to look at modifications to the CCS program which is scheduled to sunset at the end of 2015. We are currently working with the CCS Redesign Stakeholder Advisory Board to ensure that our provider members are represented throughout the redesign process of CCS.

Our goal is to ensure and protect Medi-Cal/CCS beneficiaries’ right to access to care.

Join the small handful of people who will advocate for Medi-Cal/CCS beneficiaries and emergency provider rights.

ACT NOW

If you are a medical provider who has provided emergency services and care to Medi-Cal beneficiaries that has been uncompensated because Managed Care Plans have subsequently asserted that services rendered fall under the CCS carve out and must be provided by a paneled provider, we want to hear from you. Your input is needed to accurately report this trend to the Department of Health Care Services.

Report unlawful and unfair payment practices to us. We want to hear of any Medi-Cal Managed Care Plans/CSS Non-Paneled Provider Denials that you are experiencing.

Once we confirm receipt of your input/response and sample cases showing this trend, we will provide you with updates on this policy fight along with an advisory, which includes statutory authority that currently addresses this issue.

TOGETHER we will:

  • Challenge Medi-Cal Managed Care Plans’ misuse of state and federal funds intended for eligible beneficiaries, and the emergency safety net providers that treat them.
  • Challenge the Department of Health Care Services and the Department of Managed Care to ensure that they consistently enforce California law in order to protect Medi-Cal/CCS beneficiaries’ rights and benefits.
  • Challenge Medi-Cal Managed Care Plans’ ability to follow established policies and procedures to ensure that all Medi-Cal/CCS claims at your facility are resolved consistent with California law.

Press Contact:

ERN/ The Reimbursement Advocacy Firm
Natalie Marcell, Esq.
(714) 995-6900, ext. 6911
nataliemarcell@ernenterprises.org

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This post was written by ERN Enterprises, Inc.