If you have received an L.A. Care Health Plan denial for a medical treatment or medication your doctor believes you need, it can be extremely discouraging. Many of those who fall under Medi-Cal or Medi-Cal Managed Care wrongly believe they have no recourse following an L.A. Care Health Plan denial, but this is simply not true. You can speak to a knowledgeable healthcare denial attorney from the Law Offices of Scott Glovsky as quickly as possible. In some circumstances we will help you file an appeal, and if your internal appeal is unsuccessful, we will advise you the of the best way to escalate the process.
Overview of L.A. Care Health Plan
L.A. Care Health Plan (AKA Local Initiative Health Authority for Los Angeles County) claims to be the largest publicly operated health plan in the nation, serving more than 2.5 million members in L.A. County as of October 2024. L.A. Care Health Plan offers Medi-Cal, L.A. Care Covered, L.A. Care Cal MediConnect Plan, L.A. Care’s Healthy Kids, and others. The company advertises that it prioritizes healthcare quality and access. L.A. Care Health was established in 1997; it claims that Medi-Cal Managed Care provides accessible, cost-effective health care through managed care delivery systems and networks of organized systems of care.
Only Los Angeles County residents are eligible for the L.A. Care Health Plan and must meet the income guidelines. As of January 1, 2024, a new California law allows adults between the ages of 26 and 49 to qualify for Medi-Cal regardless of immigration status. Also as of January 1, 2024, Kaiser Permanente will no longer be a contracted Plan Partner of L.A. Care for Medi-Cal, however, members of L.A. Care can get their health care from L.A. Care, or from Plan Partners like Anthem Blue Cross, or Blue Shield of California Promise Health Plan.
L.A. Care Health Plan Violations
On October 8, 2024, California’s Department of Managed Healthcare (DMHC) announced a settlement agreement of $35 million between L.A. Care Health Plan and the DMHC and a $20 million settlement agreement between California’s Department of Health Care Services (DHCS) and L.A. Care Health Plan. The settlements mandate that the plan institutes improvements to its operations to ensure it provides members with timely access to medically necessary healthcare services. Operational improvements include processing requests for care, handling grievances and appeals, processing provider disputes, and paying provider claims. Other improvements include ensuring delivery of quality and timely care through better oversight of contracted entities such as hospitals, clinics, and providers.
What if Your L.A. Care Health Plan Insurance is Partnered with Another Major Insurance Company and Independent Practice Association (IPA)?
If you’ve received an L.A. Health Plan denial and your L.A. Care Health Plan is partnered with an IPA or another major insurance company, here’s what you need to know. An IPA is an Independent Physician Association, an Independent Practice Association, or an Independent Provider Association. All of these are networks of physicians, some with both Primary Care Providers (PCPs) and specialists. Some IPAs will include doctors, hospitals, imaging centers, and urgent care clinics. IPAs allow physicians to remain independent while accessing certain benefits like reduced overhead.
Physicians may share office space and systems, electronic health records, and billing and reimbursement processes. L.A. Care Health Plan may contract with IPAs or the individual IPA physicians and facilities. The theory is that members then have access to a larger network of doctors and facilities and that practitioners are allowed to determine care. If your insurer is partnered with an IPA, there are certain incentives for the IPA to deny patient care. These incentives may be in the form of capitation payments and risk-sharing pools.
The IPA often receives capitation payments—fixed monthly payment amounts—for each member, regardless of whether that member needs medical care or not. So, if you rarely use your medical insurance, the IPA profits. If, however, you have a chronic medical condition or require hospitalization and long-term aftercare, the monthly capitation payments may not cover your medical expenses. This may lead IPAs to deny you service.
Risk-sharing pools limit the use of specific medical services because, like capitation payments, the cost of healthcare services is transferred from the insurer to the IPAs and medical providers. Some insurers place a percentage of capitation payments into a risk-sharing pool at the beginning of the year for services like hospitalization. At the end of the year, if hospitalization costs exceed the percentage held back, the IPA must bear the extra cost.
If the costs are less than the held-back amount, the IPA may receive a percentage of the funds that remain in the cost-sharing pool. Again, this gives IPAs financial incentives to deny healthcare in the interest of enhancing profits. As of February 2024, L.A. Care Health Plan contracts with 28 IPAs in Los Angeles County, including Preferred IPA of California and Regal Medical Group. If your L.A. Care Health Plan involves Medi-Cal, it can be more complex to deal with an L.A. Care Health Plan denial.
You may be required to exhaust all administrative remedies by going through the Medi-Cal appeal process potentially if your IPA refuses to approve your treatment or medication or has told you to go through step therapy. Regardless of your situation, you can benefit from speaking with an experienced health insurance claim denial attorney from the Law Offices of Scott Glovsky.
What are the Reasons L.A. Care Health Plan Might Deny Your Claim?
There are many reasons you might receive an L.A. Care Health Plan denial. Some of those reasons could be valid, while others might include terminology like “experimental,” “investigational,” or “not medically necessary.” In many cases, these words and phrases translate into “we don’t want to pay for an expensive treatment or medication.” There may be a coding error, or you may have made a mistake on your paperwork. Sometimes these issues can be fixed, and the claim re-submitted.
Your L.A. Care Health Plan might also issue a retroactive denial, which is the denial of a claim that has already been paid. If this occurs, L.A. Care Health Plan considers you responsible for the payment. Retroactive denials could be issued because a claim was paid during the second or third month of a grace period, or a claim was paid for a service you were not eligible to receive. You should always talk to your insurer about whether a specific service is a covered benefit and should always consider obtaining your medical services from an in-network provider.
If your L.A. Care Health Plan denial is the result of your insurer claiming the treatment is not medically necessary or is experimental or investigational, you may need help from attorney Scott Glovsky. If your physician believes your health will benefit from a specific treatment or medication yet your insurer denies that treatment or medication, Scott may be able to seek justice on your behalf. Our firm assists L.A. Care Health Plan Medi-Cal Managed Care members who receive their L.A. Care Health policy through Anthem Blue Cross or Blue Shield of California Promise Health – with or without an IPA. Scott has represented health insurance policyholders for twenty-five years; we hold big insurers accountable while fighting for the rights of policyholders.
What Should You Do if Your Claim is Denied?
If you’ve received an L.A. Care Health Plan denial, you can appeal that denial, asking L.A. Care to review and change an adverse decision it made about your medical treatment. You may have received a Notice of Action letter that tells you a medical service is being denied, delayed, changed, or ended. You often have the right, after receiving this Notice of Action letter, to appeal the decision within 60 days. You are allowed to continue receiving the appealed service while you wait for a decision.
You can file your appeal online, in writing, or by phone. L.A. Care then has 30 days to inform you of the appeal decision and to send you a Notice of Appeal Resolution letter. If you do not receive the appeal decision within 30 days, you can request a State Hearing from the California Department of Social Services. If you ask for a State Hearing, and the hearing has already happened, you cannot ask for an Independent Medical Review (IMR) with the Department of Managed Healthcare (DMHC), but otherwise, you can ask for an IMR. If your life, health, or ability to function would be in danger if you waited the full 30 days for a decision, you can ask for an expedited review and you should receive a decision within 72 hours.
How the Law Offices of Scott Glovsky Can Help with Your Denial
Attorney Scott Glovsky founded the Law Offices of Scott Glovsky in 1999 to hold big corporations accountable for putting profits over people. Scott strives to make a real difference in the life of every single client, changing the system in the process to ensure others don’t suffer in the same way. The Law Offices of Scott Glovsky are unique in that we have experience working on the other side, which means we understand how insurance companies think and operate.
Attorney Scott Glovsky has a sterling reputation and is well-respected in the industry, which is why many of our cases come from referrals from other attorneys. Scott and his team take fewer cases so he can personally devote a tremendous amount of time and care to every client. We offer highly personalized services as we get to know our clients, their families, and the story behind their suffering. Attorney Scott Glovsky takes pride in the passion and integrity he brings to every case and has a successful track record that showcases his devotion to his clients.
The goal of the Law Offices of Scott Glovsky is to help those who have been wronged. To that end, we promise that we will care about you as a client, listen to you, be responsive and available, and always put your needs first. We will fight hard for you, while always treating you with the dignity and respect you deserve. To combat an L.A. Care Health Plan denial, contact the Law Offices of Scott Glovsky today.