Does the DMHC Have Teeth?

Posted: July 21, 2016

by John Hansen

The Powerful Arm of the Department of Managed Health Care to Protect California Consumers

At the CAHU Capital Summit 2016 on Wednesday, May 18, Mary Watanabe, Deputy Director of the Department of Managed Health Care (DMHC), asked the rhetorical question, “Does the DMHC have teeth?” The answer is a resounding yes.

A Mighty Ally for California Consumers

The DMHC is a government agency in California that works to protect 25 million insured on California health insurance plans in the state. A year ago the department took over the conservatorship of a poorly managed health plan. That is the kind of power this department wields.

The DMHC does not have the power to set rates for health plans. However, they assess the rates of plans and make recommendations if they feel the prices are unreasonable. Resistant carriers may find that the DMHC publishes their recommendations in order to create additional pressure.

They do surveys on a cycle of 3 years to assess health care organizations. And at times they do non-routine surveys when needed.

Fines and Penalties

As far as teeth, the Department of Managed Health Care has been given the power to levy fines and issue penalties when needed in their efforts to protect California medical insurance consumers.

The DMHC is a powerful advocate for consumers covered by health insurance in California. However, most in the state have never heard of it. Mary Watanabe says, “I’m on a mission to not be the best kept secret in the state.”

File an Independent Medical Review to Tap into the Power of the DMHC

When California Health Plans illegally deny service, this is when the DMHC lion most often bears its teeth. California consumers are entitled to file an Independent Medical Review (IMR) with the DMHC. If a decision is made in favor of the client, they get the service they require. 60% of the time the consumer wins, and they get the health care service they wanted.

There is a 2 page review form to submit an issue. The form is user-friendly. Watanabe says, “We still process the form if you don’t check all the right boxes.” The DMHC is wanting consumers to contact them with issues, and they won’t deny requests for little technical errors.

Some of the key issues for the Department of Managed Health Care are:

• Timely access to care: In most cases, consumers shouldn’t have to wait for more than 15 days or 2 weeks for an appointment.

• Language services: You should get service from your health plan in the language you speak.

• Continuity of care: If you are already working with a certain physician or provider of health care and they end up leaving the network, in many cases you may be eligible to continue receiving in-network prices while continuing care with that physician.

Watanbe said, “We frequently hear about people waiting months [to receive care]. They are told they can’t get an appointment.” It’s issues like these that get the DMHC to take action.

She commented about various trends that the department is seeing. This includes delays in appointments and claims. Some consumers are having billing issues. They say, “I don’t’ know why I got this bill.” Other people have unjustly received terminations and cancellations. Regarding those incorrectly terminated, Watanabe said, “We’re getting a number of these.”