California Department of Managed Health Care enforcement actions

Kaiser Permanente Thrive Exposed is in no way affiliated with the Department of Managed Health Care

Did you know that the California Department of Managed Health Care (DMHC) makes all of its enforcement actions against Kaiser Permanente and other HMOs available to the public online? This is just one of the many Resources for Kaiser Victims we have collected for our visitors, to assist with your research as you prepare to file your own complaints.

It never hurts to show precedents of grievances similar to your own, as well as any prior actions taken by the Department. You cannot count on the overworked bureaucrats at the DMHC to connect the dots and recognize the patterns. That can take years of numerous similar actions. You have to set the narrative from day one, with a quality complaint that lays out all of the evidence, before KP has a chance to spin the facts its own way. There is no such thing as too much backup when going up against Kaiser Permanente.

Following are a few examples of DMHC enforcement actions from the last year:

On April 24th, 2019, the Department issued a Cease and Desist Order against Kaiser (and then amended it on May 29th), for denying coverage for “fertility preservation services” to cancer patients prior to medical treatment that may cause infertility, such as chemotherapy. They found a whole laundry list of violations:

• Failure to provide coverage for medically necessary physician services.
• Failure to provide specified ambulatory care services by persons licensed or authorized under California law.
• Failure to provide coverage for medically necessary diagnostic laboratory services.
• Failure to provide coverage for medically necessary preventive health services.
• The Department shall impose administrative penalties upon a determination that a Plan has interfered with the independent review process
• Failure to provide medically necessary basic health care service
• Failure to operate in accordance with organization documents filed with the Department
• Failure to provide basic health care services as set forth in the evidence of coverage.

Then on August 9, 2019 (Letter of Agreement), KP was fined $10,000 for Violation of confidentiality of Medical Information Act. The gist of it is that one Kaiser Foundation Health Plan member was improperly given the protected medical information of another enrollee, by a receptionist, and the Department concluded that a Corrective Action Plan (CAP) and an administrative penalty of $10,000 were warranted to prevent it from happening again. Kaiser seems to have done the right thing in this case, by voluntarily admitting to the breach and implementing a CAP acceptable to the DMHC. That is how it should work every time. And our critics claim we never say anything nice about KP 😉

Also on August 9, 2019 (Letter of Agreement), Kaiser was fined another $10,000 for three violations in one case: Failure to resolve enrollee grievance within 30 days (under more than one statute); and Violation of confidentiality of Medical Information Act. A member had filed a grievance with the health plan, and KP is required by law to respond and make certain disclosures within 30 days. Kaiser mailed the grievance resolution letter to the wrong address, and not only did that prevent the member from receiving it on time, but it also put her confidential medical information at risk by sending it to a stranger. Again KP did what it was supposed to do in the end, but what can be learned from this is that “the letter was mailed” is not a legitimate excuse. The burden is on Kaiser to get it to you on time, and at your registered address.

Many more DMHC enforcement actions can be found on its website. If you are contemplating filing a complaint of your own, we suggest that you browse through the history and familiarize yourself with the applicable laws, and how violations have been handled in the past. As we say on our Resources for Kaiser Victims page:

When you file an official complaint Kaiser’s MO in most cases is to circle the wagons. They will deny literally everything, and go to whatever lengths necessary to discredit the complainant. One of their go-to tactics is to pick through medical records to find something they can use to paint the aggrieved individual as mentally unstable. Examples we have seen include putting lists of any psychiatric medications on the top of the stack of numbered medical records submitted in complaints and legal actions, so that is the first thing anyone sees. One member had once mentioned to Kaiser that her father was schizophrenic. Why do you suppose KP would choose to put that particular tidbit on top of the records filed in her arbitration proceeding when it had nothing to do with her? Yes, they are that underhanded.

The point is not to discourage complaints, but rather to suggest that no matter how frustrated and angry you get at the unfairness of this process, that you always keep your cool, and methodically collect all of your evidence before Kaiser has any inkling you plan to complain. It’s hard to win but it can be done.

Words to live by.