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California insurers facing unwanted regulatory scrutiny

Does it owe to purposeful bad-faith actions or, rather, the simple inability to conduct proper oversight and maintain accurate records?

Either way, says the director of California's Department of Managed Health Care, it's "a mess."

"It" is the findings in a recently concluded state report that are, by any measuring stick, truly dismal.

The data relate to health care-related information that consumers deem critically important, namely, the list of doctors that are classified as "in-network" under their coverage plans.

Virtually every American knows how vital that information is. American health care is pricey enough when service is delivered by a network provider. If a mistake is made, resulting in care delivery by a non-network physician, patient costs can skyrocket.

Here's the problem that Shelley Rouillard, the above-cited state director, has with a large number -- candidly, most -- of health insurers in California that were recently inspected by officials: Fully 90% of them have huge glitches in the provider lists they disseminate to the public.

"[I]t looks like nobody cared," Rouillard recently noted in commenting on a 45% discrepancy rate for UnitedHealthcare's provider data. The error rate for Cigna was 36 percent, which was equaled by Anthem Blue Cross.

One patient commentator calls such magnitude of error "false advertising."

It does connote a major problem, says one health plan executive, who stated in response to the report that, "Clearly ... we have work to do."

Rouillard says that the health care provider-related regulatory compliance concerns are obvious and overwhelming and that regulators "will be holding [insurers'] feet to the fire."

Close compliance in such a realm will always be difficult, given the scope of the subject matter and the movement of doctors within the industry. An insurer with questions or concerns regarding compliance and optimal steps and processes to implement to ensure close conformity might reasonably want to contact a proven business law firm with ample regulatory-related experience.

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