Dear Substance Use Treatment Provider and Other Companies in the Industry:

The following article is a cautionary tale about being organized in how an industry deals with insurers. While Anthem was fined for not addressing client grievances in a timely manner by the Department of Managed Health Care, the lesson is what drove DMHC to act was the fact that subscribers and providers filed grievances. As you know, ATAC has asked your organization to file grievances, now you can see the result of those organizations within our industry that did, as well as of those other providers in other parts of healthcare that were experiencing the same problems. Did you file a complaint with DMHC in 2016 when ATAC requested you to complain?

While ATAC applauds the actions of the Department of Managed Health Care, shouldn't the fact that 70% of denials are eventually overturned be considered an unfair payment pattern as defined by the Health and Safety Code 1371.37? Aren't the denials simply a payment delay tactic?

ATAC will be pursuing further action by the Department of Health Care to ensure that Anthem is held fully accountable for all violations of the Health and Safety Code with respect to their actions. 

Please read the entire article:

https://www.washingtonpost.com/national/health-science/california-fines-anthem-5-million-for-failing-to-address-consumer-grievances/2017/11/15/7744cd34-ca52-11e7-b506-8a10ed11ecf5_story.html?utm_term=.e5051a6eda05 

For those who want to know all the details, here is the actual case:

http://wpso.dmhc.ca.gov/enfactions/docs/2990/1510765385688.pdf

What do you have to complain about today? Underpayments, lack of timely response to contested claims, or ever-changing coding requirements? You must complain to call attention to issues!

By CITY NEWS SERVICE | via The Press-Enterprise

The owner of a southwest Riverside County drug and alcohol rehabilitation center, who filed fraudulent medical insurance claims that netted her more than $231,000 in ill-gotten gains, pleaded guilty Wednesday, July 5 to insurance fraud and was immediately sentenced to about nine months in county jail.

By Fred Schulte, Kaiser Health News

Two Florida Medicare Advantage insurers have agreed to pay nearly $32 million to settle a whistleblower lawsuit that alleged they exaggerated how sick patients were and took other steps to over-bill the government health plan for the elderly.

FRED SCHULTE, KAISER HEALTH NEWS- DOJ alleged that the insurer made patients appear sicker than they were to collect higher Medicare payments

Read the story of when Health Net set goals and paid bonuses based in part on how many individual policyholders were dropped, avoiding paying $35.5 million in medical expenses by rescinding about 1,600 policies between 2000 and 2006.