Patient-aid group to get state grant

Times Staff Writer

State regulators are helping the groups that help insured patients fight for the healthcare they need.

Cindy Ehnes, the director of the state Department of Managed Health Care, is set to announce a $500,000 grant today to the Health Consumer Alliance.

The alliance is a statewide partnership of patient assistance programs operated by neighborhood legal services groups that help low-income residents obtain essential medical care and avoid getting swamped with unpaid claims.


The money comes from an assessment paid by Blue Shield of California to settle an allegation that it illegally failed last year to implement regulatory decisions regarding patient care and claims payments. Specifically, the department accused Blue Shield of consistently dragging its feet on paying claims for treatment that regulators required it to provide for its members.

When health plans such as Blue Shield deny a treatment ordered by a physician, patients can appeal to the department. Qualified appeals are sent to an outside contractor.

That contractor, Maximus Inc., is paid by the state agency -- not the health plans -- to find expert physicians to give each treatment denial a second look known as an independent medical review.

If the panel decides in the patient’s favor and authorizes the treatment, the health plan must pay for the disputed treatment within five days. The department said Blue Shield failed to pay on time.

Blue Shield spokesman David Seldin said the company cooperated with the investigation and now pays on time. He said Blue Shield was pleased the fine was going to a worthy cause.

“We believe in and support the independent medical review process, and we certainly think people should be aware of their rights,” he said.

Department director Ehnes made the announcement at the offices of Neighborhood Legal Services of Los Angeles County in Pacoima, an affiliate of the Health Consumer Alliance.

“One of the most fundamental rights of California health plan members is the ability to get a free-of-charge second opinion from the DMHC if they are denied a medical treatment or a medication,” she said. “This funding will help more Californians to know about the extensive healthcare rights and protections available to them under state law.”

The money will pay for a brochure explaining patient rights in 12 languages and outreach to make consumers aware of their health plan grievance and appeal rights as well as the state’s HMO Help Center. That center can be reached at (888) 466-2219, or

Complaints to the HMO Help Center involving customer service nearly doubled to 442 in 2007 from 265 in 2006. In response, the department levied more than $5 million in fines and $482,500 in technical penalties on health plans over the last two years for ignoring member complaints or not implementing independent medical review decisions properly.