State Investigates Coverage of Care Denials by San Marcos Independent Practice Association
The Department of Managed Health Care has launched an investigation into coverage denials by San Marcos-based Primary Care Associates, a for-profit independent practice association that helps HMOs review patients' requests for coverage of health services, the Los Angeles Times reports. Investigators, who are examining seven specific cases, are charged with determining whether there is a "systemic problem" with the doctor-owned PCA. The investigation was prompted by complaints by doctors from the El Camino Pediatrics practice in Encinitas that PCA on a number of occasions has denied requests for specialty pediatric care to reduce costs. Instead, El Camino doctors say PCA referred children to physicians who treat similar conditions in adults. Under state managed care rules, physician groups working with HMOs must contract with an IPA to review coverage requests. Kevin Donohue, chief counsel to the director of DMCH, said that basing coverage decisions on profit concerns is illegal, the Times reports.
According to documents filed with DMHC, PCA denied pediatric specialty care for such conditions as a chronic eye infection, a rare skin condition, a brain lesion, a cleft palate and a skull birth defect. Denials of coverage were so common, the doctors allege, that the practice group assigned an employee to fight PCA full-time on appeals; each case that PCA appealed ultimately was approved for coverage. PCA this month ended its business relationship with El Camino.
"We were too expensive because we were demanding proper care for our kids," Dr. Frederick Frumin, managing partner at El Camino, said.
Donohue said it is too early to decide whether the rejections were based on PCA cost considerations or on legitimate disagreements over care.
Wayne Knight, executive director of PCA, declined to comment (Perry, Los Angeles Times, 8/23).