The California Department of Managed Health Care (DMHC) has levied a fine totaling about $819,150 to Oakland-based Kaiser Permanente for alleged delays in handling complaints from health plan members.
"Complaints are an important healthcare right to ensure members receive the care they need," said DMHC Director Mary Watanabe. "Health plans are required by law to have a grievance and appeal system to resolve member complaints, including providing timely notice of the plan's decision in response to member complaints, in addition to providing information about how to appeal the plan's decision."
There were 61 complaints in total that contributed to the fine after the DMHC Help Center referred several member complaints to the Department's Office of Enforcement for further investigation.
The complaints included, for 14 cases, failure to timely provide the written acknowledgment of the receipt of the grievance within five calendar days, and for 54 cases, the failure to timely respond to the member's standard grievance within 30 calendar days of receipt of the grievance.
WHAT'S THE IMPACT
Health plans are required to have a grievance and appeal system to review and respond to member complaints in a timely and appropriate manner. California law requires health plans to acknowledge the receipt of a standard grievance within five calendar days, resolve the grievance within 30 days and send a written resolution to the member.
Plans must also inform members of their appeal rights, including the right to file an appeal with the DMHC if they do not agree with their health plan's resolution of their complaint.
A spokesperson for Kaiser Permanente said the grievances date back to the COVID-19 pandemic and its immediate aftermath. The health system began receiving more complaints than usual starting around 2021, when members' care needs were surging.
"While we do not agree with the size or delayed delivery of these fines, we are sorry to have missed the mark in these 61 instances in 2021, 2022, and 2023, especially with members relaying concerns or seeking additional support," Kaiser said by statement. "Since 2021, we have added staff to the team that addresses grievances to ensure we are managing them in compliance with the state's requirements, as well as to best resolve our members' concerns."
THE LARGER TREND
The DMHC encouraged health plan members experiencing issues to first file a complaint, sometimes called a grievance or appeal, with their health plan. Common issues include getting timely access to care, receiving an inappropriate charge or bill, or a denial or delay in care or treatment.
If the member does not agree with their health plan's response to their complaint, or if the plan takes more than 30 days to fix the problem for non-urgent issues, the member can contact the DMHC Help Center, which will work with the member and health plan to resolve the issue. If the member has an urgent grievance, they do not need to file with their health plan first.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.