If you have received an Accountable Health Care IPA denial, you may be frustrated and feel like you have no options. Regardless of how you get your health care, you do have options when you are facing such a denial. The best step you can take following an Accountable Health Care IPA, Inc. denial is to speak to a highly experienced insurance denial attorney from the Law Offices of Scott Glovsky. Attorney Scott Glovsky received the California Lawyer Magazine’s California Lawyer of the Year Award, and the Consumer Attorneys of California’s Street Fighter of the Year Award.
Scott Glovsky has also been designated as a Super Lawyer every year since 2006 and has been recognized by Best Lawyers every year since 2016. Scott wrote Fighting Health Insurance Denials: A Primer for Lawyers, which has become the training manual for lawyers and law firms. An Accountable Health Care IPA, Inc. denial doesn’t have to be the end of the matter. Scott will fight for justice on your behalf, ensuring you are treated with respect and dignity.
Overview of Accountable Health Care IPA, Inc.
Accountable Health Care IPA, Inc. is a physician-owned independent physician association. According to its website, Accountable Health Care “strives to become the leading integrated health service organization dedicated to promoting the personal health of members through improved communication, health maintenance, and coordinated delivery of care.” IPA may stand for Independent Practice Association, Independent Physician Association, or Independent Provider Association. Essentially, an IPA is a network of physicians. The IPA may include Primary Care Providers (PCPs) and specialists, and may also include facilities like imaging centers, urgent care clinics, and hospitals.
Physicians in an IPA remain semi-independent but receive benefits from being a part of an IPA, such as reduced overhead. The reduced overhead can be the result of shared office space, or shared billing and reimbursement processes. An individual IPA may work with multiple health plans and will typically provide longer hours and benefits like telehealth appointments.
The IPA will have more negotiating power with health insurers because it is a much bigger entity than an individual physician practice or an individual facility. The healthcare you receive comes directly from your IPA physicians and facilities, while your health insurance company contracts with the IPA to provide healthcare. In theory, members have access to a larger network of doctors and facilities, and practitioners determine their care without having to rely on approvals from the insurance company
Overview of Accountable Health Care IPA, Inc. Denial of Claims
In 2019, member Terry Larue suffered a hand injury. His health plan’s administrative approval process unreasonably delayed treatment for his injury. Larue sued his insurer, Health Net of California, as well as Accountable Health Care IPA, the practice responsible for his health care decisions. Larue settled with Health Net before trial for $4 million, then proceeded to trial against Accountable, recovering a jury verdict that exceeded $7 million. Those who have suffered an Accountable Health Care IPA denial for medical treatment or prescription drugs have options—and attorney Scott Glovsky can help you exercise your rights and options.
What Are the Most Common Reasons Accountable Health Care IPA, Inc. Might Deny Your Claim?
The contracts entered into between Accountable Health Care IPA and health insurers change the IPAs into small insurance companies that essentially provide them with real incentives to deny patient care. In exchange for payments from the insurer, IPAs agree to determine what medical care an individual needs or is entitled to receive as well as to provide or pay for the bulk of the medical care given to the individual. Specific incentives include:
- Capitation payments, which are fixed monthly payment amounts for each member assigned to the IPA. IPAs receive these capitation payments regardless of whether the member utilizes medical treatments. This means that a member who is healthy all year and does not use his or her healthcare coverage allows the IPA to receive payments with no outlay of services. A member who uses their healthcare coverage frequently could end up costing the IPA more than the capitation payment. This could result in the IPA denying care to a member.
- Similar to capitation payments are risk-sharing pools, which limit the use of specific medical services. Some insurers hold back a percentage of capitation payments at the beginning of each year, designating the money for such things as hospital stays, and placing it in a risk-sharing pool. At the end of the year, if the real cost of the hospital stay is more than what was held back, the IPA is responsible for part of the additional cost. If the real cost comes in under budget, the IPA receives a percentage of the money placed in the risk-sharing pool. If the IPA finds itself on the losing end of risk-sharing pools because several members spend considerable time in the hospital, it may attempt to deny hospitalization care to those members.
It is worth noting that in some cases, physicians have ownership interests in IPAs and, therefore, receive bonuses based on the profits of the IPA.
What Should You Do if You Receive a Healthcare Denial?
The law can be a bit complex regarding IPA healthcare denials. In some cases, you must exhaust all administrative remedies provided by the Medi-Cal appeal process. If your IPA has told you to go through step therapy, or simply refuses to approve your treatment or medication, you would benefit from speaking to an experienced health insurance attorney from the Law Offices of Scott Glovsky. Our firm helps individuals with Medi-Cal Managed Care Plans that also have a private insurance company involved. When you have a highly skilled attorney in your corner who has regularly dealt with IPAs and big insurance companies, your chances of a positive outcome after your initial denial improve dramatically. Attorney Scott Glovsky never hesitates to go up against a big insurance company or IPA and will fight for justice on your behalf.
How the Law Offices of Scott Glovsky Can Help
Depending on the situation, an Accountable Health Care IPA, Inc. denial can feel like the end of the world. When you are sick, or have a serious medical condition that would benefit from a specific medical treatment or prescription drug, receiving a denial is a very daunting feeling. You may feel like you are alone, with nowhere to turn, and no ability to make the IPA approve your treatment or medication. While it is natural for you to feel hopeless, there is hope. Attorney Scott Glovsky and his highly experienced team are ready to take on Accountable Health Care IPA—or any other insurer or IPA.
We have been fighting for our clients for twenty-five years. Cases like this can be settled out of court or at trial, but you need an attorney who is highly experienced both in and out of the courtroom. At the Law Offices of Scott Glovsky, we will develop a strategy to maximize your health care and damage recovery. The other side knows we mean business because we have extensive trial experience as well as a history of taking complex cases to trial. We are trial lawyers—we try cases, and we win. If you want a winner who will fight for your rights and your future, contact the Law Offices of Scott Glovsky today.