California's Department of Managed Health Care has reached a settlement with Accountable Health Care IPA -- a Signal Hill medical group -- over allegations that the group allowed non-medical personnel to make decisions about patient care, Payers & Providers reports (Payers & Providers, 10/25).
Accountable Health Care IPA Details
Accountable provides care to more than 148,000 patients from nine different health plans, including:
- Anthem Blue Cross of California;
- Blue Shield of California; and
- L.A. Care Health Plan.
About the Allegations
In August, DMHC issued a cease and desist order against Accountable for allegedly conducting illegal utilization reviews and making medical necessity decisions for insurers.
DMHC accused Druvi Jayatilaka, vice president of the health care group, and another employee, Ambarish Pathak, of engaging in utilization reviews on behalf of nine health plans, even though the employees are not licensed physicians.
California law requires individuals who engage in prospective medical reviews to be licensed physicians.
The reviews can lead to changes in care or denials of specific types of treatment for patients.
A DMHC spokesperson said the agency cannot say whether the decisions made by Jayatilaka and Pathak had an effect on patient care outcomes (California Healthline, 8/2).
Details of Settlement
On Oct. 4, DMHC and Accountable reached a settlement, known as a stipulated agreement.
According to the agreement, DMHC replaced its cease and desist order with a consent decree.
In return, Accountable agreed to use an outside monitor -- Frank Stevens of the Berkeley Research Group -- for at least three years to ensure that the group complies with prior medical authorization laws. The monitor also will conduct audits to determine if the medical reviews in question affected patient care.
Accountable agreed to follow any recommendations made by the monitor or DMHC.
The group also agreed to:
- Donate $500,000 over the next two years to groups that provide care to uninsured or underinsured individuals; and
- Undergo a prospective review of all claims it has handled since January 2009 and repay any improperly reconciled payments with interest.
If Accountable breaches the agreement, DMHC reserves the right to transfer the group's patients to other health care providers, according to the settlement (Payers & Providers