If you have received a Preferred IPA of California denial, you may be feeling hopeless, even helpless. When you have a medical condition that would benefit from a specific treatment or medication, yet you are unable to receive that treatment or medication because of a Preferred IPA of California denial, you should not give up. Scott Glovsky may be able to help you. Scott has been fighting for the rights and futures of Californians just like you for twenty-five years. Along with his highly skilled staff, Scott deliberately takes fewer cases which enables the Law Offices of Scott Glovsky to offer highly personalized service to each client. If results matter, we hope you will consider our track record and make an appointment to speak to attorney Scott Glovsky.
Overview of Insurance Provider Preferred IPA of California
Preferred IPA of California was founded in 1996 and has since apparently grown into one of Southern California’s largest managed care networks. Preferred IPA has contracts with more than 1,000 physicians, allowing it to efficiently contract with more than 1,000 physicians while managing the delivery of health care to more than 200,000 members throughout Los Angeles County. The Preferred IPA of California network includes the San Fernando Valley, Santa Clarita Valley, Glendale, Central Los Angeles, East Los Angeles, West Los Angeles, Hawthorne, Inglewood, Long Beach, Paramount, Torrance, and the San Gabriel Valley.
With more than 15.3 million Californians receiving Medi-Cal—and many of those getting their healthcare through an IPA like Preferred IPA of California—the medical care of these individuals may be decided by their IPA physician. While the IPA physician can make the decision to deny a claim, the IPA supplies resources and support for denial management including guidance with the appeal process. IPAs may have incentives to deny medical care. An IPA is a network of doctors who have their own practices. This may include PCPs and specialists, and, in some cases, may also include clinics, hospitals, and imaging centers. IPAs allow physicians to remain independent as they contract with health insurers, and as of 2022, it was estimated that 43 percent of California physicians were members of an IPA.
Ostensibly, physicians join IPAs to enhance patient care, but in reality, many physicians who join IPAs do so to reduce their overhead. Office spaces, office systems, electronic health records, and billing and reimbursement processes can be shared, which cuts down on costs for individual physicians. As a group, however, IPAs potentially can provide more medical services to members, including telehealth appointments, longer hours, and urgent care. Joining an IPA gives physicians access to many potential patients. IPAs sometimes may offer higher reimbursement rates to individual physicians, so profits are increased.
Overview of Preferred IPA of California Claim Denials
As noted, IPA physicians may be incentivized to deny care to patients based on capitation payments and risk-sharing pools. An IPA may receive a specific capitation payment for each member. If all the members were extremely healthy and rarely used their health insurance, the IPA profits would be high. What usually occurs, however, is that some members rarely use their health insurance, while others use it very frequently, costing an IPA substantial sums. So, there are financial incentives that may sometimes impact whether treatment is approved. Preferred IPA members can receive a Preferred IPA of California denial.
Along with capitation payments, there are generally risk-sharing pools that can also offer incentives for physicians to deny claims. Risk-sharing transfers the cost of healthcare services from the insurer to an IPA. Some insurance companies hold back a percentage of capitation payments at the beginning of the year, earmarking it for a specific service, like hospital stays. At the end of the year, if hospital stays exceeded the amount in the pool, then an IPA could be forced to pay a portion of the additional costs.
If the hospital costs did not exceed the amount in the pool, then the IPA could receive a percentage of the money remaining in the pool. In short, denying healthcare can equal higher IPA profits. Capitation contracts provide a financial incentive for physicians to see higher numbers of patients, and some doctors even have ownership interests in an IPA or receive bonuses based on the IPA’s profits.
What Are the Most Common Reasons Given by Preferred IPA of California for an Insurance Claim Denial?
There are many reasons for a Preferred IPA of California denial. Some of these reasons are related to paperwork or coding, some are the result of coverage issues, and others may be the result of a failure to follow required steps such as prior authorization, or step therapy. Some denials, however, are cloaked under words and phrases like “experimental,” “investigational,” and “not medically necessary.” In some cases, this may mean that the medical treatment is expensive, and the IPA does not want to bear the cost.
Summary of a Case We Filed
In addition to this example case summary, please view a full list of our results and client testimonials.
We filed a lawsuit against Anthem Blue Cross and the medical group Preferred IPA of California on behalf of our client due to their failure to promptly approve crucial and necessary authorization requests for specialized speech-language therapy. Our client was diagnosed with papillary squamous cell carcinoma, which required a total laryngectomy. After this procedure and the removal of her larynx, our client was unable to speak. Despite recommendations from her surgeon and ongoing requests from her doctors over four months, both Defendants repeatedly denied authorization for the therapy, resulting in our client being hospitalized three times due to complications. Our lawsuit alleges that Anthem’s utilization review system is designed to delay and deny coverage of medically necessary care, utilizes unqualified medical reviewers, and provides financial incentives to deny care. The case further alleges that this systematic failure to provide timely and necessary medical treatment constitutes bad faith conduct and violates California law.
What Should You Do if Your Preferred IPA of California Insurance Claim is Denied?
Appealing an IPA denial can be more difficult than appealing through an insurer and is a process that may benefit greatly from having an experienced claim denial appeal attorney like Scott Glovsky by your side. You have the right to appeal a denied service and must generally submit your appeal within 60 days of the IPA’s determination. A standard appeal will normally be processed within 30 working days.
If a delay in the decision would pose an imminent, serious threat to your health (such as a threat to your life, limb, or major bodily function), you can ask that your appeal be expedited. If your appeal is expedited, you will receive an answer within 72 hours. If the decision of the IPA is not in your favor, you often can request a review by the Appeals and Grievance Committee, which sometimes can be scheduled within 10 working days.
How the Law Offices of Scott Glovsky Can Help with a Preferred IPA of California Denial
If you’ve received a Preferred IPA of California denial, it can be a demoralizing experience. After all, you expect your treating physicians to fight for the treatments you need. When it turns its back on you, don’t give up.
In certain circumstances, Attorney Scott Glovsky may be able to go to battle on your behalf. Our firm helps individuals with Medi-Cal Managed Care Plans that also have a private insurance company involved. Scott’s work has impacted millions of insurance policyholders. Scott has forced big insurers to change their behavior and do what’s right for policyholders and their loved ones. If your IPA is denying, delaying, or underpaying your health insurance treatment for the wrong reasons, this may be a grave injustice.
You have the right to fight back, and the Law Offices of Scott Glovsky may be able to help you do just that. Scott founded the Law Offices of Scott Glovsky in 1999 to hold major corporations accountable for putting profits ahead of people. As a highly skilled trial lawyer, Scott routinely makes a real difference in his clients’ lives, sometimes even changing the system so others will not suffer needlessly. Contact the Law Offices of Scott Glovsky today.