Although it has improved access to behavioral healthcare for its members, Kaiser Permanente could face additional fines for not going far enough, according to the California Department of Managed Health Care.
A report (PDF) based on surveys of behavioral health files through Jan. 1, 2015, says Kaiser has taken “substantial actions to correct access to behavioral health follow-up appointments by creating and implementing a treatment plan template and an audit process that tracks the availability and timeliness of follow-up appointments.” It also said Kaiser has used an audit tool to improve access and available appointments.
“However, although the plan has undertaken extensive and meaningful efforts to resolve the issues raised by this deficiency, the plan has not provided the department with long-term, verifiable results demonstrating compliance. Thus, [Kasier] has not provided the department with evidence demonstrating it has been consistently compliant in providing enrollees with access to appointments," according to the report.
Allegations that Kaiser didn't follow state regulations go back to 2013, when the state fined Kaiser Permanente $4 million for failing to provide access to mental health services for its members. The department said at the time that Kaiser HMO members had to wait longer than 14 days, as required by state law, to see mental health providers and that errors within the insurer's tracking system caused it to underreport its members' wait times.
In a formal response to the new report, Kaiser listed more than 10 interventions it has implemented to improve members’ access to mental-health care, including contracting with providers outside of the organization and aggressively recruiting and hiring new clinicians, according to California Healthline. The plan cited internal audits finding that they complied with timely access laws more than 90% of the time and said a corrective action plan isn’t warranted.
“We have made great progress over the nearly two years since this survey was begun to improve access by hiring over 1,030 new psychiatrists and therapists, expanding our network of community practitioners, and introducing more convenient ways to access treatment,” John Nelson, vice president of government relations for Kaiser, wrote in an email to Kaiser Health News.
The state found six deficiencies that it says Kaiser has not corrected:
- It doesn’t consistently take effective action to improve care where deficiencies are identified, follow up or monitor whether the provision and utilization of services meets professionally recognized standards of practice.
- Its Quality Assurance Program does not ensure that effective action is taken to improve care where deficiencies are identified in service elements, including accessibility, availability and continuity of care.
- It doesn’t immediately notify enrollees filing expedited grievances of their right to notify the Department of Managed Health Care of their grievance.
- For expedited grievance decisions to deny, delay or modify healthcare service requests by providers based in whole or in part on medical necessity, Kaiser doesn’t consistently include in its written response a description of the criteria or guideline used by the plan and the clinical reasons for the decision
- It doesn’t consistently consider the “reasonable person” standard when evaluating the medical necessity of emergency services.
- For decisions to deny emergency services based in whole or in part on medical necessity, Kaiser doesn’t consistently include in its written response a description of the criteria or guidelines and the clinical reasons for the decision.