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NUHW investigation shows Kaiser members still having rights violated

By Meiram Bendat

On February 28, 2024, NUHW provided the California Department of Managed Health Care (“DMHC”) with a new complaint against Kaiser Foundation Health Plan (“Kaiser”), alleging continued violations of California laws cited in DMHC’s October 2023 settlement agreement with Kaiser.

NUHW’s complaint concerns ongoing access impediments for Kaiser enrollees who obtain psychotherapy through an external network provider, Path CCM, Inc., which does business as “Rula Health.” Rula Health is comprised of over 8,000 licensed non-physician behavioral health therapists and is contracted with health plans across the country to provide virtual psychotherapy to individuals, couples, and families residing in multiple states. It has been treating Southern California Kaiser enrollees since 2022.

NUHW’s complaint alleges that Kaiser (and/or the Southern California Permanente Medical Group) directed Rula Health to perform concurrent reviews of ongoing psychotherapy, typically after enrollees’ thirteenth session and then after every ten visits. Rula Health’s concurrent review protocols state that “At present, the [concurrent review] process is only in place for clients covered by Kaiser SoCal.”

Although Rula Health is not licensed or accredited for utilization management, its non-treating clinicians nonetheless audit enrollee records for medical necessity and do so without applying the exclusive screening tools (e.g., LOCUS, CALOCUS, ASAM) authorized by SB 855. According to Rula Health’s training materials, Rula Health’s reviewers do not document their concurrent reviews directly in enrollees’ medical charts, and adversely impacted Kaiser enrollees are not provided with written denial notices or due process rights. Kaiser enrollees who wish to continue to meet with their Rula Health therapists after reviewers determine psychotherapy is no longer medically necessary for them (based on impermissible standards) must self-pay.

None of this is terribly surprising. Following multiple investigations of Kaiser since 2022, DMHC determined that:

Specifically, in reference to behavioral health services, the Plan does not have an adequate system for monitoring and evaluating the care provided by the Medical Groups and external contracted providers (in-network providers that are contracted with the Medical Groups and are not directly employed by the Plan or the Medical Groups) . . .

The Enforcement Investigation’s review of enrollee medical records observed a lack of documentation in enrollee charts and treatment plans. The Plan acknowledges its difficulties in implementing effective oversight of the Medical Groups’ activities . . . The Plan also lacks sufficient oversight of the external behavioral health contracted providers . . .

[T]he Department’s review of 100 behavioral health medical records indicated that none of the medical records documented scores or criteria from the nonprofit professional associations, including LOCUS, CALOCUS, or ASAM. Additionally, the Plan did not provide clinical criteria documentation that would reflect implementation or use of the appropriate clinical criteria.

Although SB 855 was specifically enacted to protect enrollees from wrongful medical necessity denials based on impermissible standards, and although California law requires Kaiser to maintain active oversight of the services rendered by its medical groups and extended network providers, NUHW’s recent complaint reveals that Kaiser is still a long way from ensuring that its enrollees are receiving the behavioral health services to which they are entitled. NUHW is committed to holding Kaiser accountable to its obligations under the law and to working collaboratively with all stakeholders to ensure this happens.

Meiram Bendat is the founder and president of Psych-Appeal, the nation’s first private mental health insurance law firm. In addition to being a licensed psychotherapist, Dr. Bendat is the author of California’s pioneering mental health parity law, SB 855, which has served as model legislation throughout the country.

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