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Health Net Medi-Cal Denials

Computer keyboard with red Insurance denial button.Over 15 million people in California are enrolled in Medi-Cal. That’s 40 percent of the population of the entire state. Medi-Cal and the insurance companies like Health Net that contract with the program are responsible for providing healthcare coverage to millions of Californians, and while those millions of residents benefit from free healthcare, they also suffer from improper, unreasonable, and bad faith denials of coverage when they need a procedure or treatment the insurer doesn’t want to pay for.

If your claim for coverage has been wrongfully denied through the Health Net Medi-Cal plan, we want to hear from you. Our California insurance law firm has taken on Health Net and other Medi-Cal insurers time and time again, helping people like you get the coverage they are entitled to under the law.

What Is Health Net?

Health Net is one of the largest insurance companies operating in California today. The Health Net Medi-Cal plan currently enrolls more than three million people in Kern, Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare counties. Unfortunately, Health Net has also been on the receiving end of repeated claims of bad faith insurance practices. These claims come in the form of individual and class-action lawsuits, complaints to the California Department of Managed Health Care, lawsuits from local government prosecutors, and hefty fines imposed by government regulatory agencies. Among the many abuses Health Net has been accused of over the years, you’ll find:

  • Approving applications without reviewing them, and then suddenly cancelling plans when a claim is made
  • Designing a database to undercompensate consumers for out-of-network claims
  • Imposing hidden or unexpected charges to our-of-network physician visits
  • Failing to approve a timely referral to a surgeon

As a consequence of actions like these, Health Net has faced millions of dollars in penalties, fines, and lawsuit judgments, including a million-dollar fine from DMHC and a $7.2 million jury verdict our firm obtained against Health Net for its unreasonable and bad-faith tactics.

How Does Health Net Operate Its Medi-Cal Plan?

Medi-Cal is the California version of the federal government’s Medicaid program. It offers no-cost and low-cost health coverage to eligible people who live in California. Medi-Cal is overseen at the state level by the Department of Health Care Services (DHCS), with most individual cases managed at the local county level. Both children and adults may be eligible for Medi-Cal, which is a needs-based program open to people with low income or who are pregnant, blind or disabled. Persons over 65 years old may also qualify for Medi-Cal without regard to income.

Health Net’s Medi-Cal plan is HMO-based. An HMO, which stands for Health Maintenance Organization, is a particular type of health insurance plan that claims to offer a wide range of healthcare services, including preventive care and wellness programs in addition to access to specialized care as needed. HMOs purport to be more efficient and well-organized from an operational standpoint, but this managerial efficiency does not always translate into better medical care for the individual. Under the HMO model, a primary care physician (PCP) acts as a gatekeeper standing between you and medical treatment. All of your care flows through and from this doctor, so you cannot seek a specialist or other care without first getting a referral from your PCP. Of course, you would expect your PCP to have your best interests at heart, but they are contracted with the HMO and obligated by the HMO to consider cost-containment even when making medical decisions like which procedure to recommend, which drug to prescribe, or whether to approve a referral to a specialist.

This gatekeeper concept is further reinforced by requiring Medi-Cal recipients to participate in a managed care plan. Under managed care, not only will your PCP be in charge of specialist referrals, but countless procedures and services that you may need must first be approved through prior authorization from Health Net, which might claim your request isn’t medically necessary or can be met through some less expensive alternative. Health Net contracts with Independent Physician Associations (IPA) to provide care to its members. While the doctors in an IPA are treating you, they negotiate their rates with Health Net and have a contractual relationship with them.

Health Net Bad Faith Insurance Practices Hurt Our Most Vulnerable Population in California

Children in foster care, pregnant women, the elderly and disabled, and the poorest Californians are the ones receiving healthcare through Medi-Cal. When bad faith insurance practices like those that Health Net has been accused of are perpetrated on Medi-Cal beneficiaries, those actions hurt people who are desperate for medical care and cannot afford to be ill-treated. In California, the insurance law attorneys at Gianelli & Morris are here to ensure your health plan treats you fairly and hold it accountable when it doesn’t. If you have been harmed by wrongful claim denials or other bad faith conduct by a Health Net Medi-Cal plan in Los Angeles or statewide, call Gianelli & Morris at 213-489-1600 for a free consultation to explore your options and find out how we can help.

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