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Health Plan Payment Practices Threaten Patient Care

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At a time when Modern Healthcare is asking whether 2022 was the worst year ever for health systems’ income, hospitals and health systems are being forced to cope with deteriorating performance among many health plans in providing prompt and fair reimbursement. 

From failure to process “clean” claims swiftly to excessive delays on prior authorizations to navigating seemingly endless rounds of paperwork on transfers or utilization management, it’s clear that after three years of COVID-19 response and amid the ongoing hospital care crisis, many health plans have simply not stepped up, even as they have enjoyed record profits.

Last week, CHA sent a letter to Mark Ghaly, MD, secretary of the California Health & Human Services Agency, asking him to take action to address many health plans’ unfair payment practices

From the letter: “Immediate action is needed to hold health plans accountable for meeting existing requirements in state law. California’s legal and regulatory authority is clear; stricter state enforcement is needed. While this would not resolve Medi-Cal underfunding, which must be addressed, a series of actions would provide some relief and prevent even greater loss of access to hospital care.”

The letter describes the poor performance of many health plans in paying their bills on time and how this pattern endangers patient care in an environment of unprecedented financial challenges. It includes 11 specific requests to compel compliance with the state’s prompt payment laws, ensure payment for services rendered, and enhance state oversight of health plan performance.   

This statewide issue is playing out in Los Angeles County as well, where the Hospital Association of Southern California is pressing local plan L.A. Care to address similar and persistent problems with deficient payment patterns, all of which have a disproportionate impact on underserved communities. 

Next week, CHA will reach out to hospital CEOs and government relations executives asking them to submit their own letters to plans (copying the Department of Managed Health Care) to share hospital-specific concerns and challenges. These letters will help all parties be fully apprised of the reimbursement challenges you are facing and their impact on patients. 

These issues are untenable given hospitals’ precarious financial conditions and the potential for loss of access to health care services for Californians. It is time for the state to step in to ensure that California laws are being upheld.