Kaiser Permanente Health Plan Falls Short on Behavioral Health

July 06, 2017 - Kaiser Permanente’s health plan does not adequately ensure that patients can access behavioral health services in a timely and effective manner, says the California Department of Managed Health Care after a routine survey.  The report identified six major deficiencies in the plan’s behavioral healthcare services division, adding to shortcomings that led to a $4 million fine in 2013.

Kaiser is bound by California’s timely access laws, which state a patient must receive care within 48 hours for an urgent problem, or wait no more than 10 days for an appointment with a mental health provider.

In conducting its routine survey of the insurer, the state evaluated the following areas: quality assurance, grievances and appeals, access and availability of services, utilization management, continuity of care, access to emergency services and payment, prescription drug coverage and language assistance.

The survey found deficiencies in three areas: quality assurance, grievances and appeals and utilization management.

Deficiencies in quality assurance

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In this category, the state contends that Kaiser failed to plan follow-up care for enrollees when prescribed, or monitor the services to assure they met professionally recognized standards of care.

Several cases cited a delay in treatment for individual psychotherapy.  One involved a patient currently using psychiatric medication who had to wait four months for an appointment with their provider.   A second case in the report  described an enrollee who was unable to make a prescribed three week follow-up appointment with her psychotherapist.  

Another deficiency involved an enrollee diagnosed with bipolar I and a substance use disorder. The enrollee was hospitalized for suicidal thoughts at a Kaiser facility. While at that facility, the enrollee in question confronted two quality issues.  First, Kaiser delayed continuing the patient’s medication until a separate provider evaluation was completed.  Secondly, the nursing staff was unable to identify the currently prescribed medication from Kaiser’s own health record for that patient. 

These findings build upon the results of a 2012 Routine Behavioral Health Survey, where the state also cited Kaiser’s quality assurance levels.   In that previous report, the insurer was described “for failure in its quality assurance responsibilities, to ensure that effective action was taken to improve care where deficiencies were identified in service elements, including accessibility, availability, and continuity of behavioral health care.”

The current state report echoed the 2012 findings in that Kaiser “did not provide enrollees with timely access to initial appointments for behavioral health services or take effective action regarding these access problems when they were identified.”  It also faulted the payer for failing to track and provide timely follow-up appointments, or rectify problems that were identified.

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The state did acknowledge that Kaiser had made some improvements since its earlier audit, but that the current results fell well below the insurers own self-imposed compliance standards.  

Although Kaiser did present evidence of 10 targeted points of corrective action within its behavioral health quality assurance efforts, (the insurer had hired more staff, and increased out-of-network referrals), the payer lacked sufficient data to submit to state investigators.  This was because some improvements had only been implemented within months of the current audit, despite Kaiser being required to do so three to four years earlier.

Deficiencies in grievance and appeals

Two deficiencies were against the insurer in this category.   The first deficiency involved the payer failing to immediately notify enrollees of their right to file expedited grievances, or of their right to notify the California Department of Managed Health Care of their grievance.

The second deficiency reported was for patients’ rights to file an expedited grievance on any decisions made by Kaiser to “deny, delay, or modify health care service requests by providers based in whole or in part on medical necessity.”   

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This finding also includes that Kaiser did not “consistently include in its written response a description of the criteria or guideline used by the Kaiser and the clinical reasons for the decision.”

Deficiencies in utilization management

State investigators found deficiencies in Kaiser’s application of the “reasonable person” standard when evaluating its insurance coverage of emergency services both in and out-of-network.

The “reasonable person” standard in California allows the patient to subjectively determine if they need emergency department (ED) care.   To determine this, the “reasonable person” must access if a lack of medical attention would result in serious jeopardy, serious bodily impairment, and/or a serious dysfunction of an organ or body part.

Several cases of out-of-network denied claims were later determined to have fallen within the “reasonable person” standard.  These denial of coverage deficiencies were further compounded by Kaiser’s lack of a written response which described in detail the “criteria or guidelines used, and the clinical reasons for the decision.”

Kaiser had been previously fined by the state for similar deficiencies for denying out-of-network ED coverage, as well as denying the validity of ED treatment for enrollees in-network. This resulted in a 2006 administrative penalty of $500,000, of which $250,000 was suspended, but later reinstated upon Kaiser’s failure to achieve the corrective actions that were sanctioned. 

With the completion of the most recent state survey, Kaiser has a 60-day period to make a response.   Kaiser is responsible for making and reporting a plan of corrective actions for the listed deficiencies, or face additional fines and state action.   The California Department of Managed Health Care will conduct a follow-up review of the plan, and issue a status report within 14 to 16 months of June 2017.