ews ‘Artolé Schwarcenegger, Ceverner ‘Sat of Calorie Suuness Tarspotaton snc Housing Agency 980 Ninh Steet | ‘ute $00 Sacrrarto, CA S534 ‘Tos__Dan Chest, Kaiser Foundation Health Pian From: Andrey Googe | Bet__OMH Provider Complaint No, £63: Foe ae Pages: 8 Phone: Date: 0507/2008 co: xUrgent CO ForReview i Piaase Comment [1 Please Reply OPtease Recycte | @ Comments: named above and may contain Inform: to its intended recipient is strictly pro! message in error, please notify the immediately and retum the original address above by mail legally privileged. Any dissemination or di This facsimile message is intended only for the use of the individual or entity In that is confidential, non-public or ution of this message other than bited. if you have received this ent of Managed Health Care age and ail copes to us at theosz87 pm 08-07-2008 ‘VIA FACSIMILE and US. MAIL i May 7, 2008 ‘Mr. Dan Chesir Kaiser Foundation Health Pian 2101 Webster Street, &th Floor | Onkiand, CA 94612 Provider: San Francisco General Hospital | Patient: Heather Galeotti | DMHC Provider Complaint No. 9831 | Dear Mr. Chesir: ‘The Department’s Office of Provider Oversight | ‘referenced complaint. In “his matter, San Francis / seeking payment of approximately $4.1 million | ‘from February 27, 2007, through September 27, j ‘2007, response to the Department, the Plan is terminated Ms. Geleott’s coverage effective J completed its review of the above- General Hospital (“SF General”) is \claims for care provided to Heather Galeotti 107. According to Kaiser's December 5, ing coverage for these claims because it 1, 2007. to pay claims from SF General from the , 2007, the date upan which the: ‘Ms. Galeotti was admitted to SF General on February 27, 2007, after being seriously injured | when struck by an automobile. Kaiser was promtly notified of her admission ané confirmed har eligibility. Tae Plan's case management noted indicate that from the date of her admission. | ‘through July of 2007, there were frequent and, daily, communications between the Plan's case managers and SF General, During thib time, SF General was providing treamment | | and communicating with Kaiser based upon the Plan's represemations that she wos an eligible | | Keiser member. As indicated in the Plan's responses 10 the ions “ith Plan represeniatives, itis clear that from . Galeotti could not have been safely ‘0 p Kaiser facility; nor was Kaiser offering or | reoommending a transfer. Rocolved ay #708 2:348 a To-aalth Plan Reguiato Paxe 002—— cea omens ‘SF. General Hospital 0831) | May 7, 2008 ‘Kaiser Foundation fleas Plan Page? | Although the Plan's dambase indicated that she remained eligible ul the time, on of about June | 20, 2007, Kaiser became aware of problems with Ms. Galeotti's eligibility. Kais toen ‘unsuccessfully attompied th verify eligibility via. ‘with the group contract holder, General Employee's Trust Fund (“GETF”). On Jhly 23, 2007, Kaiser received the attached {facsimile from GETF, indicating that Ms, Galeotti was ast eligible for coverage ox Deceraber 31,2006. This facsimile did not smate the reason for Ms, Galecti's ineligibility, nor di it | Specifically direct Kaiserto terminate her 03 ofthat date. Kaiser has represeated to the Department that this is the only written ¢ that GETF issued to Kaiser segarding the termination. Pursuant to receiving this facsimile, the Plan isoued the attached j Notice of Termination to Ms. Galeotti's father on July 25, 2007. Te notice indicated shat Ms. | Goleott's coverage was being terminated effect! January 1,2007, On Angust 7, 2007, Kaiser formally notified SF Goncral that Ms. Galgptti was no longer eligible for coverage. She has since obtained coverage through the } ‘Program, ANALYSIS 1. Kaiser Authorized the Cure Provided to Ms, Galeotti and is Prohibited From | Rescinding the Authorization, | eal & Sety Code section 1371.44) requis ‘health plans reimburse providers for | emergency services and care provided to em ‘until the care results in stabilization. Rule | n 1300.71 4 sets forth the requitemens for provid stabilization of an emergency medical condition afd | Smnsieered. This Rule requires a health plan to p | ‘the plan’s fiilure to do so results in the care being fi | toquires a plan to pay for all medically Health care services provided to an enroltee i ived condition until the enrollee can be emergency care at a non-Plan facility, ive Review Program, an essential ' care or arrange for safe repatriation to & | Kaiser maintains a 24/7 telephonic Emergency P:¢ function of which is o either uuthorize them | Kaiser facdity. ‘treatment, the services could be on care, the fact is that the services were ¢ management notes are replete with references that no post stabilization care was auth: i, existing law does. ‘Kaiser to.confirm eligibility and pllow extensive medically necessary care to be provided to a ember WHS Was uneble to be tan ing the position thet the cafe was not sotborized oe ie "Having morized these services, Kaiser is now prphibite for rstinding the authorization Health and Safety Code section 1371.8 provides ti -service plan that authorizes specific type of treatment by a provider stall or modify its authorization aller the “fovea Sndonl tele ee faith and pursuant to the authorization. ‘Brovidier tts fen peal care sex = Recoivod ay-OT=t8 02:80 | Toeslth Plan Rogu.ate Page 002‘S¥. General Hospi (9831) Kaiser Foondation Health Plan ‘As referenced above, these services were aut payment was conditioned upon a post inasev vactive Ana 2, Kaiser Failed to Comply With a Specific P longer than fhree months, unless agreed to ia following regarding retroactive cancellation of protect Plan members from the harsh effects of a ‘was ignored by Kaiser. Given Kaiser apparently accepted this facsimile from membership terminetion form, despite the at t | termination. Lastly, despite receiving this ince ‘the Galeotti's were maintaining that their daughts 8 May 7-08 98:34 —_— they were provided in good faith and pursuant to 4 elighiiy. tn providing thee sevioes, SF General > acide andthe Pan anaDWWable 1S SF Gener Prohibited a Seven Month Retroactive Termini ‘The group coatract between Kaiser and GETF ey “Group must repo membership changes: considerable detriment off Ms, Galeotti and SF Geter os22epm 05-07-2008 a \n in its Group Cantract That tion. oe ive cmninass ‘by Kaiser. Tais agrecment states the iP: nluding sending appropriate membership es. The time limit for retroactive ““Healtt plans purchaser handbook includes details about howto report membership changes.” Page 15 of the Purchaser Handbook provides the ra | “You should report membership changes (including appropriate membership forms) | ‘as soon as possible. If a revroactive is requesied, there is a time limit. You | ‘may make retroactive membership | as far back as two months prior to the calender month in which the Kaiser CSC receives the notice of the change, unless Kaiser Permanente agrees in writing. n months baci, at least four months longer cits own contractual provision to the financial obligation to SF General, and con the Family Kaiser's motives re SUSPECT Adaitionally, it was back to January 1, 2007; the above- direct the Plan to do so. Moreover, remained m eligible dependent, the Plan | | made no independent determination regarding her|eligibility, but simply accepted the G1STF | facsimile. Torkeslth Plan Remulato Fase 004| ofMs, Galeotti's coverage, Additionally, | 2. Provide the Department with a written | aww | oe ‘Kaiser Foundation Health Pian \ 1a effectunting this retroactive emnination and ‘group health plan contract, the Plan is operating, document filed under its Knox-Keene license, : pursuant tn Health & Safety Code section 1386(b} eee cee pm. 05.07.2008 sa— ‘May 7,2008 Page 4 ‘ — 2by failing to abide by the terms of the ‘variance with s basic organizational is therefore subject to disciplinary action 1). Te 3, Kaiser's Notice of Termination Failed to Comply With the Requirements of the ‘Knox-Keene Act, ccantract giving rise to the right of cancellation. ‘Provide this infomation. The fact that this info of the fact that normal termination procedures ‘canolusicn that the Plan's goa! atthe time was to $i Ms ec evn men mation elcome at re xv ‘in good faith. Kaiser was well aware of is and daring her admission, continued to receive full Jhad no basis to ignore the contrectual retroactive significant Sinancial windfall at the expense of! Frogram. Accordingly, Kaiser is directed to do 1, Pay all claims associated with health care 27,2007, through August 7, 2007; and rights to continuing coverage that were follow the provisions ofits group health plan: ‘terminating Ms. Galaotti's coverage. dant pending financial obligation for her caro, ‘premium on the Family account. The Plan sion other than to achieve a Galeotti, SF General and the Medi-Cal fallowing: Ms. Galeotti recsived from February outlining how the Pian will remedy any as aresalt of the Plan’s failure t and the Knox-Keene Act, in ‘Please provide written confirmation to me within ten (10) business days of the date of thid letter that the Plan has complied with this directive. “Thank you for your pronipt attention to this matter. Senior Counsel Enclosure(s) Mey-07-08 92:34ee Fo)