Fixing fees is California’s most important Medi-Cal improvement.

Is California having a harder time with health plans that include Medi-Cal, the state’s insurance program for low-income citizens?

A few weeks ago, state regulators were put in place a $ 55 million in penalties at LA Care, California’s largest Medi-Cal care program, for failing to ensure adequate care and allowing medical delays to threaten the health of the registrars. Advocates believe the move will signal stronger enforcement against other Medi-Cal providers, many of the same shortcomings that LA Care regulators have blamed.

Twenty-five state-of-the-art care programs provide care for nearly 12 million of the more than 14 million Californians enrolled in Medi-Cal, and the state has been repeatedly sued for failure to maintain arrangements for subpar care. Medi-Cal members are one of the state’s most vulnerable: They can face language and cultural barriers and have high rates of chronic illness.

The state Health Care Services, which runs Medi-Cal, is developing a new care agreement, expected to take effect by 2024, officials say will improve care by keeping health plans at high levels. The state aims to reduce health disparities and improve health outcomes by increasing monitoring and implementation.

“They’re trying to do more, and that’s really good,” said Abbi Coursolle, senior attorney at the National Health Law Program in Los Angeles. “Obviously, they have a lot more to do.”

DHCS and the state Department of Managed Health Care, which oversees Medi-Cal care plans, began the LA Care systematic study, based on a 2020 Los Angeles Times report on shows long, sometimes fatal, delays in maintenance in laboratories. run by the Los Angeles County Department of Health. That agency uses the county’s public safety system and agreements with LA Care to provide care for hundreds of thousands of members of the health care system. In their investigation, state officials also relied on LA Care’s information to them.

They relied on these factors, Coursolle said, to raise questions about the validity of their own observation and evaluation.

On March 4, the Department of Managed Health Care fined LA Care with a $ 35 million fine – more than three times its previous maximum salary. The Department of Public Health spent $ 20 million, nearly eight times its original history.

The state told LA Care of more than 100,000 offenses, including late response to complaints and medical malpractice, delaying and denying permits for adequate health care, and non -confirmation of care. Health care department’s compliance with health care regulations. The California Department of Health, which oversees hospitals and other health care departments, did not respond to a question about investigating any of the county’s health departments.

Announcing the payoffs, state officials said: “LA Care’s seriousness of the offense, which has resulted in damage to its members, needs to be acted upon immediately.” There are 2.4 million people enrolled in the health program.

“The ongoing enforcement action against LA Care signals DHCS’s intention to use our powers to protect our Medi-Cal enrollees,” office spokesman Anthony Cava said. me by email.

LA Care CEO John Baackes said the project does not conflict with data. “What we’re struggling with is a lot of costs, which we think are unfair,” Baackes said. The debate took months or years.

In a statement released after the payments were announced, LA Care noted Medi-Cal’s low pay to providers and said the penalties would create “a financial problem for a public health plan is an important part of the health care safety net. “

While LA Care has raised millions of dollars in recent years, it has reported a loss of $ 132 million in fiscal year 2020. But costs can be adjusted. At the end of last year, its independent net – a major measure of solvency – was seven times higher than the minimum required by law.

The breaches described by the editors are very common to Theresa Grant, a Culver City resident I wrote about late last year who was looking to find relief from a debilitating injury. inside his bone plate. “The crime is terrible,” he said, “and I think it’s very true.”

But he believes the doctors can’t and don’t want to help him correct most of the guilt. “You know how long I’ve been dealing with my problem,” he told me. “It’s been a year now, nothing bad is happening.”

Despite severe penalties imposed on LA Care, consumer advocates and some state attorneys believe California should have the power to tax higher taxes.

The bill, supported by consumer support group Health Access, would increase the amount of fees that state health planning providers can incur by about ten percent. Proponents say the law, SB 858, is necessary because the agency has not increased the amount of office involved in health care plans in some cases since 1975.

“We want to make sure that insurance companies don’t see these fees as the cost of doing business,” said the bill’s author, state Sen. Scott Wiener (D-San Francisco). “By increasing them, they become less costly and more motivated to follow the law.”

The penalties imposed on LA Care are much higher because of their size, determined by the number of offenses. “For every salary like that, a lot of things are very low,” Wiener said. “I don’t want to rely on one case and say, ‘Yeah, no problem, because they’ve got a big salary.'”

Another key factor in keeping the feet of health plans on fire, Wiener said, is that consumer complaints can help bring the problems to the attention of regulators – and own designs.

But a report last year by KFF revealed that few customers are being neglected.

If you have a problem with your health plan or want to complain about delaying or denying coverage, the Department of Managed Health Care is a good place to start (888-466-2219 or HealthHelp.ca.gov) .

The state has an ombudsman for Medi-Cal care management (888-452-8609 or [email protected]).

You can try the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org), which helps people with comprehensive and personal health plans. It offers free counseling, offers legal services, and can help you get your documents to appeal.

Regulators and health care providers often say they work on behalf of the patient. So if you don’t get the care you need, stand up and be a part of the outcome.

This story was created by KHN, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.

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