Administrators Ordered To Stop Making Patient Care Rulings

California managed care regulators are ordering a doctors’ group to stop letting business administrators make decisions about granting requested medical care, according to www.califoriawatch.org. The order targets Accountable Health Care IPA. Regulators say that the chief executive’s son and another manager made calls on patient care that, by law, should be made by a doctor.

The state Department of Managed Health Care issued 12 cease and desist orders to Accountable, a Los Angeles doctors’ group that provides care for 148,000 patients. The orders are also aimed at large insurers that contract with Accountable, including Blue Cross, L.A. Care, Aetna, Health Net, Blue Shield and others. Those orders ask health plans to stop enabling its contractor to violate state law.

Accountable Health Care IPA denies the department’s allegations.

The July 16 orders allege that Accountable Health Care IPA allowed unqualified executives to perform medical reviews involving a modification or denial for requested medical services. The orders say the decisions were reached on many occasions since Dec. 24, 2008.

The orders also allege that Ambarish Pathak, a utilization manager, and Druvi Jayatilaka, vice president and the CEO’s son, may have ruled on patient care matters on more occasions that are now concealed because the company does not track who completed medical reviews of requested care. Orders were sent to the managers ask them to stop violating the state’s Health and Safety code.

The state’s managed care watchdog agency is pursuing the case as more than a million low-income Californians who rely on Medi-Cal are about to be added to managed care plans. The state will be providing a flat per-patient fee to large insurers, many that will, in turn, delegate everyday care of those patients to independent practice associations, like Accountable Health Care.

Last Updated 9/8/2017

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