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Blue Shield of California Promise Health Plan Medi-Cal Denials

Blue Cross Blue Shield headquarters signage and logo. Blue Cross Blue Shield is a federation of health insurance organizationPromise Health Plan is a health maintenance organization (HMO) owned and operated by Blue Shield of California. Formerly known as Care 1st Health Plan, Blue Shield of California Promise Health Plan provides Medi-Cal managed care services in San Diego County. It has been providing health plans under one name or another since 1995 and has been providing health care services to Medi-Cal beneficiaries in San Diego under contract with the Department of Health Care Services (DHCS) since 2005. As of 2021, Promise Health Plan had nearly 100,000 members in San Diego.

In 2020, DHCS conducted an audit of Blue Shield of California Promise Health Plan. The audit report, issued in June 2021, covered key areas of utilization management, access and availability of care, member’s rights, and quality management. What the audit found was concerning yet not surprising. Read about the audit report below, and contact the California insurance law attorneys at Gianelli & Morris if you have been the victim of an unreasonable claim denial or other bad faith insurance practices by Blue Shield of California Promise Health Plan.

Utilization Management

Utilization management covers the ways insurance companies review requests for medical treatment and decide whether the requested treatment is medically necessary or not. It is something insurance companies often get wrong, and it lies behind a great number of complaints that an insurer is acting in bad faith by wrongfully claiming a particular procedure is not medically necessary as a pretext to deny coverage. In the case of Promise Health Plan, the audit found that the HMO did not include a review of grievances and appeals of prior authorization denials in its quality improvement strategy as required. When interviewed by DHCS, the Plan admitted that not only was it not reviewing reports on these denials, it wasn’t even creating them.

Access and Availability of Care

This category includes the requirement to provide transportation for non-emergency yet medically necessary services. The audit revealed that Promise Health Plan was not following the proper procedures for determining the appropriate level of service for Medi-Cal members. Many Medi-Cal members rely on covered transportation to access needed medical care rendered by licensed providers, but Promise Health Plan’s lapses made it likely Medi-Cal recipients would be unable to receive the transportation, and hence the treatment, necessary for their medical condition.

Member’s Rights

Medi-Cal beneficiaries have the right to access a grievance system when they have a problem with their insurer, and the Plan is required to keep and submit a written record of grievances. Promise Health Plan was found not to be complying; it did not submit a written record of grievances, nor did it refer grievances internally as required or fully resolve grievances submitted by Medi-Cal enrollees. Blue Shield didn’t even provide its members with correspondence in the member’s languages as required by law.

Quality Management

Where Promise Health Plan fell down here regarded its duty to deliver adequate quality of care to its members and take action to address needed improvements in its provider network. Blue Shield did not ensure that its providers were trained on Medi-Cal Managed Care as required.

If you are receiving Medi-Cal coverage through Blue Shield Promise Health Plan CA, you don’t have to settle for substandard medical care or be the victim of bad faith insurance practices. If your claim for a medical procedure was unreasonably denied based on excuses that the procedure is experimental or not medically necessary that mask the insurer’s true motive of denying the claim to save money, then you could be entitled not only to the benefits due under your policy but also significant compensation for the additional harm Blue Shield’s bad faith conduct has inflicted on you. This can include punitive damages in appropriate cases, which can greatly increase the size of your monetary award and hold Blue Shield fully accountable for the damage done. Contact Gianelli & Morris to speak with a California bad faith insurance law firm with a record of going up against insurance giants like Blue Shield of California and coming out on top.

Gianelli & Morris – Hitting Back Hard When Bad Faith Medi-Cal Insurance Hits People the Hardest

Wrongful denials of coverage for important medical services are bad enough when they hit people who might be able to cover the treatment out-of-pocket and then seek reimbursement through grievances or legal action. But when bad faith actions are taken through a Medi-Cal plan like Blue Shield Promise Health Plan CA, they hit people who can ill afford to have their claim for medical treatment denied. Medi-Cal serves the lowest-income Californians and the state’s most vulnerable categories of people, including the elderly, disabled, pregnant women, and children in foster care.

At Gianelli & Morris, we have experience taking insurance companies to task for wrongful claim denials impacting children with special needs and adults with urgent medical needs. We understand the toll that an unreasonable delay or denial can have on anyone in need of medical care, including especially our state’s most vulnerable residents. Our law firm is committed to standing up to the insurance giants and forcing them to act as they should, providing the coverage for medical care which should be their primary mission.

If you are a Medi-Cal recipient who’s been the victim of bad faith insurance practices by Blue Shield of California Promise Health Plan, call Gianelli & Morris for a free consultation at 213-489-1600, serving Californians in San Diego, Los Angeles and statewide.

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