The California Department of Managed Health Care recently issued a cease and desist order against Accountable Health Care IPA -- a Signal Hill medical group -- for allegedly conducting illegal utilization reviews and making medical necessity decisions for insurers, Payers & Providers reports.
Accountable Health Care IPA Details
Accountable provides care to more than 148,000 patients from nine different health plans, including:
- Aetna;
- Anthem Blue Cross of California;
- Blue Shield of California; and
- L.A. Care Health Plan.
DMHC Accusations
DMHC has 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.
According to Payers & Providers, 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. The spokesperson said the case still is under investigation (Payers & Providers, 8/3).