Anthem Blue Cross Dental Final Report

OFFICE OF PLAN MONITORING DIVISION OF PLAN SURVEYS

FINAL REPORT

ROUTINE SURVEY

OF

ANTHEM BLUE CROSS DENTAL

A DENTAL HEALTH PLAN

DATE ISSUED TO PLAN: AUGUST 19, 2015 DATE ISSUED TO PUBLIC FILE: AUGUST 31, 2015

Template Revision Date: 05/03/19

Final Report of a Routine Survey Anthem Blue Cross Dental

A Dental Health Plan August 19, 2015

TABLE OF CONTENTS

EXECUTIVE SUMMARY ________________________________________________ 2

SURVEY OVERVIEW __________________________________________________ 6

SECTION I: DISCUSSION OF DEFICIENCIES AND CURRENT STATUS _________ 8

QUALITY ASSURANCE _______________________________________________ 8 GRIEVANCES AND APPEALS ________________________________________ 31 ACCESS AND AVAILABILTY OF SERVICES _____________________________ 37 UTILIZATION MANAGEMENT _________________________________________ 40 LANGUAGE ASSISTANCE ___________________________________________ 50

SECTION II: SURVEY CONCLUSION ____________________________________ 61

Anthem Blue Cross Dental Final Report of the Routine Survey August 19, 2015

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EXECUTIVE SUMMARY

On December 4, 2012, the California Department of Managed Health Care (the “Department”) notified Anthem Blue Cross Dental (the “Plan”) that its Routine Survey had commenced, and requested the Plan to submit information regarding its health care delivery system. The survey team conducted the onsite portion of the survey from February 5, 2013 through February 8, 2013. The Department completed its investigatory phase and closed the survey on May 15, 2015.

The Department assessed the following areas:

Quality Management Grievances and Appeals Access and Availability of Services Utilization Management Language Assistance

The Department identified 16 deficiencies during the current Routine Survey. The 2012 Survey Deficiencies table below notes the status of each deficiency.

2012 SURVEY DEFICIENCIES TABLE

# DEFICIENCY STATEMENT

QUALITY MANAGEMENT

1

The Plan does not ensure that: • quality of care provided is consistently

undergoing review by clinical professionals to identify problems;

• effective action is taken to improve care where problems are identified; and

• follow-up is planned where indicated. Rule 1300.70(a)(1); Rules 1300.70(b)(1)(A), (B), and (C)

Not Corrected

2

The Plan does not adequately oversee entities conducting credentialing functions on behalf of the Plan, nor does the Plan ensure that all participating providers and their staff are licensed and/or certified, as required by law. Section 1367(b); Rule 1300.70(b)(1)(A) and (D); Rule 1300.70(b)(2)(B); Rules 1300.70(b)(2)(G)(1) through (4)

Not Corrected

3

The Plan has not established complete policies and procedures to guide its activities in the event that it is required to file an 805 report. Rule 1300.51(J)(b)(3); Rule 1300.70(a)(1); California Business and Professions Code Section 805

Corrected


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4 The Plan is operating at variance with its Quality Assurance Program as filed in its application for licensure. Section 1352; Section 1386(b)(1)

Not Corrected

5

The Plan’s Quality Management Program is not adequately directed by an appropriate provider/clinician, nor does the Plan ensure that there is sufficient administrative and clinical staff support to carry out quality assurance activities for the Plan and the Plan’s delegated entities. Rules 1300.70(b)(2)(D) through (F)

Corrected

6

The Plan’s governing body does not receive reports that are sufficiently detailed to include findings and actions taken as a result of the Quality Assurance Program, and that identify those internal or contracting provider components that the Quality Assurance Program has identified as presenting significant or chronic quality of care issues. Rule 1300.70(b)(1)(A); Rule 1300.70(b)(2)(C)

Not Corrected

GRIEVANCES AND APPEALS

7

The Plan does not fully address the requirements for the online grievance submission process. Specifically, the Plan’s online grievance process does not:

• Include a hyperlink on the home page or member services portal clearly identified as “GRIEVANCE FORM”; and

• Include the Department’s paragraph as required by Section 1368.02(b).

Section 1368.015; Section 1368.02(b)

Not Corrected

8

The Plan does not consistently acknowledge enrollee grievances and appeals in writing within five calendar days of receipt, nor does it consistently include the date the Plan received the grievance within the written acknowledgment letter. Section 1368(a)(4)(A); Section 1368(a)(4)(A)(ii); Rule 1300.68(d)(1)

Not Corrected


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9

The Plan does not fully address the requirements for expedited review of urgent grievances in its written policies and procedures. Specifically, the Plan’s procedures do not provide for:

• Plan response to the Department’s contacts/communications regarding urgent grievances 24 hours a day, 7 days a week;

• the scheduling of qualified Plan representatives, including back-up Plan representatives as necessary, to be available 24 hours a day, 7 days a week;

• notification to the Department at least 30 days in advance of implementing revisions to the urgent grievance system; and

• Plan response to the Department within 30 minutes after initial contact from the Department during normal working hours and within one hour during non-working hours.

Rules 1300.68.01(a) and (b); Rule 1300.68.01(b)(2)(A)

Not Corrected

ACCESS AND AVAILABILITY OF SERVICES

10

The Plan does not have a documented system for monitoring and evaluating accessibility of care, including a system for addressing problems that develop, which shall include, but is not limited to, waiting time and appointments. Rule 1300.67.2(f); Rule 1300.67.2.2(d)

Corrected

UTILIZATION MANAGEMENT

11

The Plan’s written communications to enrollees and providers regarding decisions to deny or modify health care services based on dental necessity, the Plan does not consistently provide or include:

• a clear and concise explanation of the reasons for the Plan’s decision;

• a description of the criteria or guidelines used; • the clinical reasons for the decisions; • a licensed health care professional evaluated

the clinical issue involved; and • the name and direct telephone number or

extension of the health care professional responsible for the denial or modification in its written response to providers.

Section 1367.01(h)(4); Section 1386(b)(1)

Not Corrected


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12

The Plan does not effectively review the dental care services rendered to its enrollees to identify problems, including over- and under-utilization of services, and take effective action to improve care. The Plan does not review its clinical criteria on an annual basis to ensure that such criteria or guidelines are consistent with sound clinical principles. Sections 1363.5(b)(1) through (3); Rule 1300.70(a)(1); Rule 1300.70(b)(2)(G)(5)

Not Corrected

LANGUAGE ASSISTANCE

13

The Plan failed to demonstrate that: • it has updated its assessment of enrollee

language needs and enrollee demographic profile at least once every three years following the initial assessment in 2007;

• it collects, summarizes, and documents enrollee demographic profile data in a manner that enables the Plan to maintain confidentiality of personal information and to disclose the information to the Department on request for regulatory purposes and to contracting providers on request for lawful purposes, including language assistance purposes and health care quality improvement purposes.

Rule 1300.67.04(c); Rule 1300.67.04(e)(1)

Not Corrected

14

The Plan failed to demonstrate that it adequately provides training for its staff regarding its Language Assistance Program. Rule 1300.67.04(c)(3)(A-D); Rule 1300.67.04(c)(4)

Not Corrected

15

The Plan does not monitor its Language Assistance Program and make modifications as necessary to ensure compliance. Rule 1300.67.04(c); Rule 1300.67.04(c)(4)(A)

Not Corrected

16

The Plan’s contract with providers does not specifically require compliance with the Plan’s Language Assistance Program standards. Section 1367.04(f) Rule 1300.67.04(e)(4)

Not Corrected


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SURVEY OVERVIEW

The Department evaluates each health care service plan licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975.1 At least once every three years, the Department conducts a Routine Survey of a Plan that covers major areas of the Plan’s health care delivery system. The survey includes a review of the procedures for obtaining health services, the procedures for providing authorizations for requested services (utilization management), peer review mechanisms, internal procedures for assuring quality of care, and the overall performance of the Plan in providing health care benefits and meeting the health needs of the subscribers and enrollees in the following areas:

Quality Management – Each plan is required to assess and improve the quality of care it provides to its enrollees.

Grievances and Appeals – Each plan is required to resolve all grievances and appeals in a professional, fair, and expeditious manner.

Access and Availability of Services – Each plan is required to ensure that its services are accessible and available to enrollees throughout its service areas within reasonable timeframes.

Utilization Management – Each plan manages the utilization of services through a variety of cost containment mechanisms while ensuring access and quality care.

Language Assistance – Each plan is required to implement a Language Assistance Program to ensure interpretation and translation services are accessible and available to enrollees.

The Department issued the Preliminary Report to the Plan on May 18, 2015. The Plan had 45 days to file a written statement with the Director identifying the deficiency and describing the action taken to correct the deficiency and the results of such action. The Plan has an opportunity to review the Final Report and file a response with the Department prior to the Department issuing the Final Report and making the Final Report public.

This Final Report addresses the most recent Routine Survey of the Plan, which commenced on December 4, 2012 and closed on May 18, 2015.

PLAN BACKGROUND

The Department of Corporations licensed the Plan to operate as a specialty health care plan on January 7, 1993. In 1997, the Plan merged with Blue Cross of California (“Blue Cross”), and surrendered its WellPoint dental license. Since then, the Plan has become

1 The Knox-Keene Act is codified at Health and Safety Code section 1340 et seq. All references to

“Section” are to the Health and Safety Code unless otherwise indicated. The regulations promulgated from the Knox-Keene Act are codified at Title 28 of the California Code of Regulations section 1000 et seq. All references to “Rule” are to Title 28 of the California Code of Regulations unless otherwise indicated.


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a division of, and currently operates under the licensure of, Anthem Blue Cross, which is owned by WellPoint Health Networks, Inc. In 2004, Anthem Blue Cross and WellPoint Health Networks, Inc. merged to become WellPoint, Inc. WellPoint, Inc. is a national for-profit entity, and is currently the Plan’s parent entity.

The Plan serves approximately 166,626 commercial enrollees in 25 California counties through two dental products. The Plan’s Dental Net product is a traditional Dental Health Maintenance Organization (DHMO) plan that provides coverage for the most commonly used dental procedures. Membership primarily consists of groups but a few individual members remain, as the product was open to individual membership at inception. The Plan’s SelectHMO product is available for individuals and covers all procedures that were listed in the CDT codes at the time the product was developed in the 1990’s. Both products provide capitation payments to contracted general dentists.

The Department last surveyed the Plan in March of 2010, and identified eight (8) deficiencies at that time. Of the eight (8) deficiencies noted, seven (7) remained uncorrected at the time the Department’s findings were presented to the Plan in the Final Report on January 3, 2011. The Department initiated a Follow-Up Survey of the uncorrected deficiencies in June of 2012, which was still in progress at the time of the February 2013 on-site survey.

The Department issued the Follow-Up Report to the 2010 Routine Survey on June 13, 2013. Two deficiencies remained not corrected. In grievances and appeals, the Plan continued to be deficient in sending grievance acknowledgement letters within five calendar days of receipt of the grievance. In addition, the Department pended issues regarding the Plan’s lack of appropriate references to the Evidence of Coverage provisions on benefit coverage, as well as exclusions and limitations, for continued review during the 2013 Routine Survey. In utilization management, the Plan had not corrected the deficiency regarding rendering written notifications consistently including clear and concise explanations of the reasons for the Plan’s decisions. Issues regarding the Plan’s lack of inclusion of the criteria or guidelines used for Plan decisions were pended for continued review during the 2013 Routine Survey.


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SECTION I: DISCUSSION OF DEFICIENCIES AND CURRENT STATUS

On May 18, 2015, the Plan received a Preliminary Report regarding these deficiencies. In that report, the Plan was instructed to:

(a) Develop and implement a corrective action plan for each deficiency, and (b) Provide the Department with evidence of the Plan’s completion of or progress

toward implementing those corrective actions.

The following details the Department’s preliminary findings, the Plan’s corrective actions and the Department’s findings concerning the Plan’s compliance efforts.

DEFICIENCIES

QUALITY ASSURANCE

Deficiency #1: The Plan does not ensure that: • quality of care provided is consistently undergoing review by

clinical professionals to identify problems; • effective action is taken to improve care where problems are

identified; and • follow-up is planned where indicated.

Statutory/Regulatory Reference(s): Rule 1300.70(a)(1); Rules 1300.70(b)(1)(A), (B), and (C)

Assessment: The Plan could not demonstrate that its quality assurance processes ensure that the quality of care issues are being consistently reviewed, that clinical professionals are consistently involved in that review, that problems are being identified, and that effective action is taken to improve care where problems are identified. Additionally, the Plan does not ensure that it conducts planned follow-up when it has identified problems.

The Department identified the following concerns with the quality review process:

1. The Plan’s methods for identifying cases involving quality concerns for review by clinical professionals are ineffective.

Rule 1300.70(a)(1) requires that the Plan “document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated.” [Emphasis added.]

The Department reviewed 50 grievance cases classified as exempt grievances by the Plan to assess whether potential quality of care issues were present and identified as required by Rule 1300.70(a)(1). Nine of the 50 exempt grievance cases (18%) involved quality of care issues. Instead of routing these cases to the Grievance Department for


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investigation and clinical quality review, the Plan closed the cases and did not conduct, nor document, any clinical quality reviews.

The Department also identified two practices that may have contributed to this misclassification. First, contrary to typical industry practice, the Customer Service Representatives have not been provided with guidelines developed by clinical personnel (e.g., the Quality Management Department and/or Dental Director) to assist them in identifying cases that may involve a clinical component so that they are properly classified as standard grievances that undergo clinical review. Second, the Compliance Manager, who has no clinical background, reported that she makes decisions regarding which grievances to refer for clinical review. Possibly also contributing to the failure to identify quality issues, the Dental Director reported that the grievance process is fragmented because it was moved away from the onsite Plan location, and it is therefore difficult to integrate the grievance and quality assurance processes.

Exempt Grievance Case Examples:

Case # 243729845: The Plan received a telephone grievance on 2/1/10 and closed it the same day. The enrollee stated she had a 5:00 pm appointment at the dental office. When the enrollee arrived, the office staff was rude and dental technician “hurt her.” Multiple issues were noted in the case by Plan staff including- rude staff , enrollee being hurt, the enrollee not wanting to be billed and/or pay copay as she was not seen by the dentist, and “horrible” service. Customer Service only noted the exempt grievance as a "directory request" and assigned the enrollee to a different office. The potential quality issues (e.g., being hurt, rude staff, poor service) were never forwarded for additional review.

Case # 244983774: The Plan received a telephone grievance on 8/10/12 and closed it the same day. The enrollee stated that the provider performed “crowns on same tooth (#7) 6-7 times” and kept messing up. The enrollee advised Plan staff that the dentist said he could not do anymore “free work on member’s teeth” and yelled at her. The Plan noted this exempt grievance as a “quality” issue, but pursuant to Plan procedure, Customer Services closed it and never forwarded for additional quality review.

Case # 242500380: The Plan received a telephone grievance on 4/19/11 and closed it the same day. The enrollee contacted the Plan regarding dissatisfaction with a bridge. According to case notes, the enrollee stated that the bridge had “never fit right and that the tooth was too big and when [the enrollee] bites it would flip and cause him to choke.” Customer Service noted the exempt grievance as a “quality” issue, transferred the enrollee to another dental office, and then closed the case. The potential quality issues involved did not receive additional clinical review.


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TABLE 1 Exempt Grievance File Review

FILE TYPE NUMBER OF FILES ELEMENT COMPLIANT DEFICIENT

Exempt Grievances 50

Evidence Plan routed cases to the grievance department for investigation and clinical review.

41 (82%) 9 (18%)

2. The Department identified the following concerns with the corrective action

process:

a. The Plan does not implement effective corrective actions for identified issues.

Rule 1300.70(a)(1) requires the Plan to “document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated.” [Emphasis added.]

The Plan’s potential quality issues (PQI) policies and procedures state that corrective action is the responsibility of the Quality Improvement Committee. The Department reviewed the Quality Improvement Committee minutes and found little detailed information or analysis of grievances; the minutes merely recorded the action taken. A corrective action warning letter to the provider was the most common action taken.

The Department reviewed the warning letters and found that the warning letters to providers were simply copies of the resolution letters sent to the patients. The “warning” consisted of a description of the issues, but did not provide any guidance on how a provider should correct the complaint or how to prevent a recurrence of a similar grievance in the future. Furthermore, the Plan did not request a correction plan from the provider to describe specific corrective actions to resolve the problem. As a result, the corrective action phase of the grievance and PQI processes is ineffective.

b. The quality assurance process is delayed.

Rule 1300.70(a)(1) requires the Plan to “document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated.” [Emphasis added.]

In order for corrective action to be effective and to ensure that it improves care, the Plan must review and implement any corrective actions in a timely manner. However, the Department found that a delay occurs at the Quality Improvement Committee level. Minutes from Quality Improvement Committee meetings show that a quality issue can be 90-days-old when reported to the committee in order to allow time for Plan staff to document fully the details and actions taken before officially reporting the issue. This makes it difficult for Plan staff to expeditiously address overall issues or trends and


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integrate direction from the Quality Improvement Committee evolving from overall issues or trends into their quality management activities.

c. The Plan does not ensure it performs clinical reviews when it identifies grievances that require clinical review.

The Department’s review of seven standard grievances that involved a potential quality of care issue found that in two cases (29%) the provider did not respond to the request for medical records:

Standard Grievance File #2: The member called to file a grievance regarding the treatment plan she and her husband received and an excessive wait time. The member and her husband were scheduled for a routine cleaning at the same time. Both were told they needed deep cleaning and periodontal treatment, despite having no history of periodontal issues. The member insisted the provider perform a routine cleaning only.

In response to the Plan’s investigation, the provider did not furnish the x-rays to substantiate the need for periodontal treatment. The Plan’s resolution letter indicated that the member's responsibility for the routine cleaning was zero co-pay and that they could not address the excessive wait time at the provider's office. There was no indication that the Plan sent a follow-up request for the x-rays from the provider to confirm the quality of care complaint.

Standard Grievance File #31: The member filed a written grievance stating she went to her dentist due to tooth pain and was told she had fractured a tooth. The member was experiencing intense pain and asked for numbing. The dentist allegedly stated that there was no medical reason to numb her, and her insurance would not cover this procedure. The member was given a prescription for pain medication and sent home. When the member continued to have intense pain and swelling, the member called the dental office and was told she was referred to an endo-specialist and she was no longer a patient of the dentist. The Plan requested medical records but the dentist did not provide the records. Thus, the Plan was unable to review the records to substantiate the member's complaint. The Plan simply closed the grievance and stated they would re-open it if they received records. Thus, the Plan failed to perform clinical review.

The failure to follow-up with providers who fail to respond to requests for records was not an isolated incident. In seven out of 49 standard grievance files (14%), the providers failed to respond to the Plan’s requests. In four of these seven instances (57%), the Plan closed the grievances and stated they would reopen it if they receive the records. Without fully investigating each grievance the Plan cannot be certain that it “adequate[ly] consider[s] and rectif[y]” enrollees’ grievances, as required by Section 1368(a)(1).

These findings are in conflict with the representations made during the interview with the Plan, where the Grievance and Appeals Department Manager and a Grievance Coordinator stated that upon receipt of a grievance from Customer Service, a Grievance


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Coordinator acknowledges the grievance and initiates the investigation process by requesting the appropriate dental records from providers.

Notably, the Provider Contract and Provider Reference Manual require that providers participate in the Plan’s Dental Quality Assurance Program and comply with the requirements of the Knox-Keene Act. The network bulletin #104, Subject: Grievance Resolution Records Request Policy states:

At the present time, Blue Cross of California expects providers as a condition of their contract, to submit the requested records. The response should include:

• A written narrative response to the allegations. • Pertinent x-rays. • Copies of the member’s chart including periodontal

probing, clinical finding, treatment plan, informed consent documentation, medical history and other meaningful information.

We allow the doctor five (5) working days to respond. Blue Cross of California now considers non-compliance to provide documents as a breach of contract. As such, penalties may include automatic finding in favor of the member and/or Credentials review and possible termination.

The Department found that the Plan is not enforcing this provision, resulting in the Plan’s inability to investigate all quality of care concerns and to take effective action based upon the evidence. This failure renders the Plan unable to ensure “adequate consideration of enrollee grievances and rectification when appropriate” as required under Section 1368(a)(1). By disregarding the Plan’s record requests, providers effectively avoid investigation, and the Plan is unable to determine if corrective actions are necessary to address quality of care issues.

The Plan does not track the number of cases that it could investigate due to providers’ failure to submit requested records.

TABLE 2 Standard Grievance File Review

FILE TYPE NUMBER OF FILES ELEMENT COMPLIANT DEFICIENT

Standard Grievance Identified as Potential Quality Issue

49

Evidence of receipt of appropriate dental records by providers

42 (86%) 7 (14%)

d. The Plan does not ensure that it conducts clinical reviews when it identifies


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cases with potential quality issues.

The Plan has a duty to perform a clinical review to confirm the appropriateness and quality of treatment as part of its PQI investigation under Rule 1300.70(a)(1). Quality of care and financial issues are often related. The Department reviewed a PQI file, which was composed of five individual grievances involving one provider. In these five grievances, the Plan did not assess and document whether the treatment quality was within expected professionally recognized standards of practice as required under Rule 1300.70(b)(1)(A). These five grievances, stemming from one provider, show that due to the lack of clinical records, the Plan is not able to determine whether it should have confirmed a quality of care issue and implemented corrective action.

Relevant Case Examples:

Grievance #1: A patient alleged that he was told he needed two quadrants of deep cleanings instead of a routine cleaning and that his child was overcharged for the extraction of five primary teeth. This grievance was initially categorized as a quality of service issue by the Grievance Coordinator but subsequently changed to over/under diagnosis (a quality of care issue) by the Plan’s Dental Director. The Compliance Manager’s summary indicated that there was no clinical review, and the Plan did not present any other documentation of a clinical review. It is not clear how the Dental Director re-classified the case. Plan staff reported that all documents for the case were present. However, it appears that the provider never submitted patient records; radiographs would have been necessary to confirm the diagnosis for the deep cleaning and extractions. The provider’s resolution letter did not contain a corrective action plan.

Because of inadequate documentation and processing of the case, the Department was unable to determine whether the Plan should have confirmed a quality of care issue and implemented a corrective action plan.

Grievance #2: A patient alleged that she had a cleaning but was charged for periodontal maintenance (a periodontal procedure performed after a deep cleaning). This grievance was categorized as a quality of care issue. The resolution letter reported the patient was not charged for periodontal maintenance but was charged for localized delivery of anti-microbial agents into crevicular tissue and a periodontal exam. The patient records did not include radiographs to confirm the diagnosis of periodontal disease, and the Plan did not conduct a clinical review. The provider was copied on the patient’s resolution letter, and there was no corrective action plan.

The two possible issues are as follows: (1) the provider may have inappropriately charged for a periodontal exam (which may have already been performed if the patient received a comprehensive exam) and (2) the provider may have unnecessarily recommended localized delivery of anti-microbial agents into crevicular tissue. Although the treatment issue was initially classified as a quality of care issue, the Plan’s final decision was not documented. Because the Plan did not adequately document and process the grievance, the Department was unable to determine if the Plan should have confirmed a quality of care issue and implemented a corrective action plan.


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Grievance #3: A patient alleged that he was overcharged and not given treatment options. The Grievance Coordinator categorized the issue as benefit determination, but the category was later changed to provider charges. The clinical review concluded that treatment options were not given properly and that the Plan did not cover additional charges for a periodontal evaluation and full mouth debridement. The clinical review did not report if these procedures were appropriate for the clinical situation. Although part of the patient record was present, the records necessary for appropriate clinical review, the periodontal charting and radiographs, were not present.

Due to inadequate documentation and processing, the Department was unable to determine if the Plan should have confirmed a quality of care issue and implemented a corrective action plan. The Quality Improvement Committee minutes directed that the provider be sent a warning letter, but the letter did not include a corrective action plan. As required by policy, the Quality Improvement Committee minutes reported the issue, and directed that the provider’s office be followed up on for six months for repeat grievances. During that period, the provider accumulated two additional grievances after the initial threshold of three. The Plan continued to follow this provider as a PQI in the Quality Improvement Committee but prepared very little detail.

Had the details of each of the provider’s grievances been documented and analyzed in the meeting minutes, the Committee would likely have realized that the provider continued to repeat the same problems—most of the grievances were related to periodontal treatment, deep cleanings, extra periodontal treatment, and poor communication. The Quality Improvement Committee failed to recognize or document this pattern. The Plan should have communicated these issues to the provider, and it should have counseled the provider.

Grievance #4: A patient alleged that she was not informed of the treatment provided and was overcharged. The Grievance Coordinator categorized this grievance as a provider charge issue. Parts of the patient record, including radiographs, were present, but the Plan did not conduct any clinical reviews nor prepare a corrective action plan.

The patient was charged for an oral cancer exam, which is part of a comprehensive exam and, therefore, may have already been performed. The full mouth debridement and localized delivery of anti-microbial agents into crevicular tissue may not have been needed; the treatments were not documented even though these were not covered services. A corrective action plan, if written, would have included improving patient communication, unbundling procedure codes, and possibly, overtreatment. The Plan did not conduct a clinical review to determine whether debribement was necessary and did not present a corrective action plan to the provider. Because of inadequate documentation, the Department was unable to determine if the Plan should have confirmed a quality of care issue and implemented a corrective action plan.

Grievance #5: A patient alleged that he wanted a regular cleaning, but was treated for a deep cleaning with localized delivery of anti-microbial agents into crevicular tissue. The grievance was categorized as a provider charge issue. The Plan requested patient records from the provider, but they were not submitted.


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It is possible that this was a quality of care issue, but the Plan did not perform a clinical review. Because of the absence of clinical records, the Department was unable to determine if the Plan should have confirmed a quality of care issue and implemented a corrective action plan.

Rule 1300.70(a)(1) requires every plan to have a Quality Assurance Program documenting that the quality of care provided is being reviewed and that any problems are identified. Rules 1300.70(b)(1)(A) through (C) require that a level of care which meets professionally recognized standards of practice is being delivered to all enrollees, that problems are identified and that appropriate licensed clinical professionals (i.e. dentists) are an integral part of the Quality Assurance Program. The Department found that the Plan’s clinical professionals did not consistently review quality concerns to identify problems. The Plan’s methods of identifying grievances for review are flawed, as grievances are not consistently classified and forwarded for clinical review. Additionally, even when cases are identified as requiring review, the Plan does not ensure that providers submit dental records to affect such reviews.

Rule 1300.70(a)(1) also requires that effective action is taken to improve care where deficiencies are identified. The Plan does not consistently implement corrective actions because it does not specify nor require deficient providers to specify a corrective action plan. Additionally, the Department found delays in review of, and action on, confirmed problems by the Plan’s Quality Assurance Committee results in violations of Rule 1300.70(a)(1).

Because the Plan does not the ensure that quality of care is consistently reviewed by clinical professionals to identify problems and it does not ensure that prompt and effective action is taken to improve care where problems are identified, the Department finds the Plan in violation of Rule 1300.70(a)(1) and Rules 1300.70(b)(2)(A) through (C).

Corrective Action: Within 45 days following notice of a deficiency, the Plan is required to file a written statement with the Department signed by an officer of the Plan, describing any actions that have been taken to correct the deficiency.

Plan’s Compliance Effort: The Plan implemented grievance processes specifying that the California Dental Director and/or licensed dentists review exempt and standard grievances to ensure services rendered meet applicable standards of care in a timely manner. The Plan also submitted the guidelines and process aids developed to assist its staff in the processing and handling of grievances. In addition, the Plan implemented a process to ensure the California Dental Director and/or licensed dentists receive medical records to facilitate clinical review of potential quality issues.

The Plan completes a new Clinical Professional Review Grievance Cover Sheet for all grievances received. This coversheet is presented at each of the Plan’s Grievance Committee meetings. The Plan’s California Dental Director and/or clinical designee, along with the Plan’s Compliance Manager and designated Grievance and Appeals Analyst, attend each Grievance Committee meeting. To ensure that it performs clinical reviews of grievances, the Plan stated that its “Grievance Committee meets as needed typically twice per week, to investigate all quality of care and quality of service concerns and to make decisions for effective and immediate action based upon the


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documentation submitted.” Furthermore, the Plan stated, “When the Grievance Committee determines that corrective action is necessary, a corrective action letter is written by the Dental Director describing the issue, the Plan’s findings, the Plan’s recommendations, request for a corrective action plan, and a response from the provider within 30 days.”

When the Dental Director identifies a potential quality issue, he takes immediate action and subsequently reports initial findings, a copy of the corrective action letter, a copy of the office’s response, and further action to the Quality Improvement Committee. The Dental Director requests the Quality Improvement Committee to review the issue and comment whether the corrective action was satisfactory or whether further action is required. When a provider fails to provide requested documentation to the Plan within five business days, the Plan will send a breach of contract letter to the provider. Failure to respond to the breach of contract letter within five business days will initiate a corrective action including withholding of new enrollment from the Plan or termination from the network.

Final Report Deficiency Status: Not Corrected

Based upon the corrective actions undertaken, the Department has determined that this deficiency has not been fully corrected. While the Plan has implemented processes to ensure the Dental Director and/or licensed dentist reviews all grievances to ensure services rendered meet applicable standards of care in a timely manner, corrective actions are developed in a timely manner, and that providers send medical records to facilitate the Plan’s investigation, it has not provided sufficient proof to show that it has fully corrected the deficiency.

During the Follow-Up Survey, the Department will assess the following:

• The Plan’s processes for identification, investigation, and categorization of quality of care issues.

• The Plan’s review, documenting and processing of both Category I2 and Category II3 grievances.

• The Plan’s process for requesting and receiving medical records to facility its investigation of potential quality issues.

• The Plan’s grievance and potential quality issue logs with supporting case documentation which provides evidence that the Plan identifies quality issues, that corrective actions are being implemented, and follow-up is applied on a timely basis, where applicable.

• Meeting minutes for the Board of Directors, Quality Improvement Committee, and Grievance Committee, providing evidence these committees have addressed quality issues timely and at the appropriate level.

2 The Plan classifies standard grievances as “Category I” grievances. 3 Section 1368(a)(4)(B) exempts plans from responding or resolving grievances in writing, if the grievances are received by telephone, by facsimile, by e-mail, or online through the Plan’s Internet Web site, are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and are resolved by the next business day. These exempt grievances are classified as “Category II” grievances.


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Deficiency #2: The Plan does not adequately oversee entities conducting

credentialing functions on behalf of the Plan, nor does the Plan ensure that all participating providers and their staff are licensed and/or certified, as required by law.

Statutory/Regulatory Reference(s): Section 1367(b); Rules 1300.70(b)(1)(A) and (D); Rule 1300.70(b)(2)(B); Rules 1300.70(b)(2)(G)(1) through (4)

The Plan’s Delegated Credentialing Policy and Procedure document describes specific on-going monitoring of delegated credentialing activities, including:

• Assessing written policies and procedures for credentialing and recredentialing every 36 months

• Assessing dedicated credentialing and recredentialing staff and resources • Assessing whether the Dental Director and a functioning credentialing committee

oversee the credentialing and recredentialing process • Reviewing annually either 5% or 50 (whichever is less) credentialing and

recredentialing files to ensure that the credentialing and recredentialing activities are appropriately performed in compliance with Plan standards, policies and procedures

• Requiring an annual/semi-annual report by the group practices of all credentialed and recredentialed dentists for each year to ensure data is accurately reflected in Plan systems.

SmileCare Audits

The Plan delegates credentialing/recredentialing functions to SmileCare, a contracted provider serving 7,665 Plan enrollees. Plan policies, as well as Delegation Agreements, state that the Plan will perform annual audits of its delegates. However, the Plan did not perform any delegation audits of SmileCare during the two-year survey look-back period4 but did perform audits in 2006 and 2008.

The Department interviewed the Credentialing Manager who reported that the Plan did not audit SmileCare during the timeframe when it was a Knox-Keene licensed health plan, but the Plan is considering performing new audits and should have an arrangement to do so by January 1, 2013. However, SmileCare has held a Knox-Keene license since 1982 and, as noted above, the Plan did perform audits in 2006 and 2008. The Compliance Manager reported that Plan policies and procedures delineate that as long as SmileCare is audited by the Department and holds a Knox-Keene license, the Plan would accept an attestation in lieu of an audit. The Department reviewed Plan policies and procedures and found no such provision, nor did the Plan submit an attestation for SmileCare. When responsibility for credentialing and re-credentialing is delegated to a contracted provider without the associated delegation oversight by the Plan, the Plan is unable to ensure these obligations have been met. The Department

4 The Survey look back period for this report was November 1, 2010-October 31, 2012.


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finds that the Plan has not performed adequate oversight of its credentialing function delegated to SmileCare.

BrightNow Dental Audits

The Plan also delegates credentialing/re-credentialing to BrightNow! Dental, another contracted provider serving 4,792 Plan enrollees. The Department is concerned that the Plan did not conduct effective oversight. The Plan did conduct annual audits and, given the unsatisfactory results of the single audit that it conducted in the survey period, the Plan did not respond in a timely manner with adequate corrective actions.

The Plan performed only one audit of BrightNow! during the two-year survey look-back period. Although the Plan did not specify the actual date of the audit, the report indicated the Plan assessed dental files from 2011. When asked why the Plan did not audit this provider annually as stipulated in its policies, the Compliance Manager reported that since they had never fully completed the 2011 audit, the Plan considered the 2012 audit as a continuation of the 2011 audit. The provider was still working on correcting some of the 2011 deficiencies in 2012 and therefore did not feel it should audit 2012 files because these would have the same deficiencies as the 2011 files. The Compliance Manager reported that the Plan was continuing the process of following up on the audit deficiencies.

The Department reviewed the WellPoint audit tool, which includes audit criteria and describes the audit process. No evidence was provided that in its audit of BrightNow!, the Plan performed the first three elements of its policy:

1. Assess written policies and procedures for credentialing and re-credentialing every 36 months;

2. Assess dedicated credentialing and re-credentialing staff and resources; and 3. Assess whether the Dental Director and a functioning Credentialing Committee

oversee the credentialing and re-credentialing process.

The Department found several concerns with the audit process:

• There was no indication that the providers’ ‘yes’ responses to a Disclosure Question (e.g., items concerning criminal offenses, suspension of license or liability insurance) were reviewed.

• In two instances professional liability insurance was verified more than 180 days prior to the file being complete.

• The audit tool requires that the National Practitioner Databank (NPDB) be queried. Eight of the 20 files (40%) failed to have this critical step completed in the audit process.

According to the Plan’s Credentialing Policies and Procedures for Re-credentialing, “To ensure that the information obtained from re-credentialing files is consistent with system information used to pay claims, and in directories: Credentialing Personnel audit standards are invoked to ensure all documents are present and current. Credentialing Personnel must maintain a 90% average on completed files.” If the Plan had applied this standard BrightNow! would have failed the audit.


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The Plan’s own auditors expressed concerns by making the following recommendations:

• BrightNow! must ensure that DEA verification is readable. • BrightNow! must ensure Disclosure Questions are completed within 180 days of

file completion date (process date). • BrightNow! must ensure that all files are readable. • BrightNow! must ensure Provider Consent, Signature and Date is current and

present in every file. • BrightNow! must ensure proof of Professional Liability coverage for each

provider.

Section 1367(b) requires that contracted providers “be licensed or certified by the respective board or agency, where licensure is required by law.” Further, Rules 1300.70(b)(1)(A) and (D) requires the Quality Assurance Program be designed to ensure that “a level of care which meets professionally recognized standard of practice is being delivered to all enrollees” and that care delivered is “consistent with professionally recognized standards of practice.”

Rule 1300.70(b)(2)(B) requires that, “to the extent that a plan’s [Quality Assurance] responsibilities are delegated within the Plan or to a contracting provider, the Plan documents shall provide evidence of an oversight mechanism for ensuring that delegated quality assurance functions are adequately performed.” Rules 1300.70(b)(2)(G)(3) through (4) permit a plan to delegate selected quality assurance activities. If a plan chooses to delegate an activity, it must meet certain criteria, including conducting “ongoing oversight” (e.g., audits) to ensure “that enrollees receive health care consistent with professionally recognized standards of practice.” Because the Plan does not conduct effective oversight to ensure that the delegated credentialing function is adequately performed and that all providers are appropriately credentialed, the Department finds the Plan in violation of Section 1367(b); Rule 1300.70(b)(1)(A) and (D); Rule 1300.70(b)(2)(B) and Rule 1300.70(b)(2)(G)(1-4).


Plan’s Compliance Effort: As part of its corrective action, the Plan submitted delegated credentialing policies and procedures which highlights the Plan’s processes for oversight, pre-assessment of delegated entities, approval process, ongoing monitoring of delegates and audit process. The Plan stated in its response that it has begun the process of auditing SmileCare5 and Bright Now! for 2014. The Plan submitted correspondence to both SmileCare and Bright Now! requesting credentialing and re-credentialing information within 30 days from date of request. Plan policy stipulates that if an entity fails to pass the annual audit with a score of 90% or higher, the Plan will review documents upon receipt and notify the group in writing of the audit results. If deficiencies are identified, the Plan will note the process for correction in written notification, will meet with the group to discuss deficiencies, and set a date for re-audit 5 Community Dental Services dba Smilecare surrendered its Knox-Keene License on March 26, 2014.


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no less than six months after the initial audit. The Plan reaffirms it will adhere to the credentialing policies and procedures going forward, conduct annual audits, and provide quarterly reporting to its Quality Improvement Committee.


Based upon the corrective actions undertaken, the Department has determined that this deficiency has not been fully corrected. While the Plan has submitted polices for credentialing and re-credentialing delegated entities, as well as correspondence to both SmileCare and Bright Now! requesting credentialing and re-credentialing information, the Plan failed to provide evidence showing that it completed the audit process. The Department will review audit results during the Follow-Up Survey.

Deficiency #3: The Plan has not established complete policies and procedures to

guide its activities in the event that it is required to file an 805 report.

Statutory/Regulatory Reference(s): Rule 1300.51(J)(b)(3); Rule 1300.70(a)(1); California Business and Professions Code Section 805.

Assessment: The California Business and Professions Code section 805 requires a Knox-Keene Act licensed health plan to file an 805 report with the relevant licensing agency when certain disciplinary actions (e.g., termination of a provider’s network membership) are taken by a Plan’s peer review body, or when specified actions (e.g., provider resignation from network membership, withdrawal of application) occur after notice of either an impending investigation or rejection of an application due to a medical disciplinary cause or reason.

The Plan has not fully developed policies and procedures relating to peer reviews or assessments of quality issues that might result in disciplinary action reportable on an 805 report. The national Credentialing Committee of Anthem Blue Cross conducts most credentialing for the Plan. In the event of an adverse action against the provider, the Plan policy on Judicial Review Hearing and 805 Reporting simply provides for fair hearing proceedings prior to reporting a cause for action under California Business and Professions Codes section 805(b). The policy does not describe

possible reporting processes and specific deadlines for submitting an Adverse Action to the Dental Board and National Healthcare Integrity and Protection Databank (HIPDB) through 805 reporting should a situation requiring 805 reporting be encountered. Additionally, the Policy does not establish specification of persons responsible for report submission, timeframes, notice to the provider, and other aspects of reporting required by Section 805. The availability of an established process for submission of an 805 report will assist the Plan to meet the short timeframe (15 days) and specified requirements of 805 reporting.

The Dental Director reported that there had been no cases requiring 805 reporting


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within the review period.

Rule 1300.70(b)(2)(C) requires that “the plan's governing body, its QA committee, if any, and any internal or contracting providers to whom QA responsibilities have been delegated, shall each meet on a quarterly basis, or more frequently if problems have been identified, to oversee their respective QA program responsibilities.” [Emphasis added.] Further, Rule 1300.70(a)(1) “the QA program must be directed by providers and must document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated.” Under Business and Professions Code section 805, the Plan’s Peer Review Committee has specific obligations to report certain events and disciplinary decisions or actions within a statutory timeframe. Under Rule 1300.51(J)(b)(3), the Plan must have written “procedures and methods for the enforcement of the standards and norms of the system.” Further, these procedures should include the Plan’s obligations to follow-up and oversee their respective QA Program activities, which include the reporting requirements under Business and Professions Code section 805. Should a situation requiring 805 reporting arise, the Plan has inadequate policies and procedures to guide it in reporting the case to the relevant agency as required under Section 805.


Plan’s Compliance Effort: As part of its corrective action, the Plan developed policies and procedures relating to peer review or assessments of quality issues that might result in disciplinary action reportable on an 805 report. This policy serves as a guide to the Plan in its activities, in the event that an 805 report of dental disciplinary cause or reason necessitates submittal to the Dental Board of California. Furthermore, the policy describes the Plan’s reporting processes between the Plan’s peer review body, Credentialing Committee and the Dental Director denoting specific timeframes for submitting an adverse action including to the Dental Board. Additionally, the Plan provided credentialing policies regarding dentist termination from the Plan’s network, which stipulates that the effective date of termination of a dentist is 14 calendar days from the date the Plan sends a letter to the dentist. The Plan will report the dentist to the National Practitioner Data Bank, and per requirements set forth by the State of California, file an 805 report within fifteen days of the termination, when required.

In its response, the Plan stated it had not terminated a provider for medical disciplinary cause or reason since the date of the onsite survey in February 2013.

Final Report Deficiency Status: Corrected

Based upon the corrective actions undertaken, the Department has determined that this deficiency has been fully corrected.


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Deficiency #4: The Plan is operating at variance with its Quality Assurance Program as filed in its application for licensure.

Statutory/Regulatory Reference(s): Section 1352; Section 1386(b)(1)

Assessment: The Department identified inconsistencies between the Plan’s written documents and the structure and operation of its Quality Assurance Program. The Plan changed its operations over time without making corresponding amendments to key documents and filing these with the Department.

The following are examples of changes and inconsistencies between the Plan’s written documents and the structure and operation of its Quality Assurance Program:

• The Anthem Blue Cross Dental Quality Assurance Program includes the following statement on page 3: “Anthem Blue Cross does not delegate any Quality Assurance responsibilities to contracting providers or any other entity.” However, the national Credentialing Committee conducts most credentialing, formerly a function of the Quality Improvement Committee. This committee submits lists of credentialing recommendations to the Plan’s Quality Improvement Committee, although the lists do not include detailed information.

• The Plan has established delegated credentialing agreements with two large providers, SmileCare and BrightNow!. These agreements are not reflected in the Quality Management Organizational Chart from December 2012, nor is the delegation agreement performed by DeCare Dental’s national Credentialing Committee, which is a subsidiary of the Plan, that performs national credentialing. The document, “Narrative Description of All Committees That Have Responsibility for Quality Management, DMHC Routine Pre-Survey Material, Plan’s Operational Activities Conducted November 1, 2010 – October 31, 2012”, erroneously reports that the Quality Improvement Committee has sole responsibility for quality management.

• The Anthem Blue Cross Dental Quality Assurance Program includes the following statement on page 18: “For offices with less than 100 assigned members, three requests for transfer by a member in a six-month period will trigger a review. For offices with 100 or more members assigned, requests for transfer by members of more than 5% in a six-month period will trigger a facility audit.” When asked how the Plan tracks transfers and whether the Plan had performed any such audits, Plan staff stated in interviews, “We no longer do that.”

• There are multiple versions of the Anthem Blue Cross Dental Quality Assurance Program (QAP).

o The version submitted to the Department as part of the Plan’s pre-onsite

document submission for this current survey had no date.


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o The redlined version submitted onsite as part of the Survey (eFiling

#20130053) is an improvement over the previous version but still contains inconsistencies and incomplete information. For example, the new language is vague concerning who reports to the Board for the Plan and what reports are submitted. Further, the Program Description does not accurately describe the monitoring of PQIs and later only vaguely mentions PQI review as a function of the Quality Improvement Committee. It appears the Plan amended part of the current Program Description on June 29, 2012. The effective date is unclear.

• The redlined version of the Program Description presented to the Department onsite did not contain provisions for an annual Quality Improvement Workplan, although the Plan had created a Quality Improvement Workplan (QI WP) for 2012.

Section 1386(b)(1) provides grounds for disciplinary action should a plan “operat[e] at variance with basic organizational documents” filed with the Department (e.g., policies and procedures, annual reports, application for licensure). Section 1352 requires that “within 30 days after any change in the information contained in its application … a plan must file an amendment …” Because the Plan has changed operations significantly and failed to file an amendment the Department finds the Plan in violation of Section 1386(b)(1) and Section 1352.


Plan’s Compliance Effort: As part of its corrective action, the Plan stated it filed an updated version of its Quality Assurance Program as an Amendment with the Department on January 7, 2013, (Filing Number 20130053) prior to the onsite which occurred on February 5, 2013 through February 8, 2013. The Department’s surveyors were notified of this filing during the onsite review, and as such, were evaluating an old version of the Plan’s Quality Assurance Program.

In response to the deficiency, the Plan indicated that its procedures did not contain provisions for an annual Quality Improvement Workplan, the Plan attested that this document is part of the National Committee of Quality Assurance accreditation process for evaluation of medical plans and therefore, not applicable to dental plans.


The Plan’s Anthem Blue Cross Dental Quality Assurance Program language is vague concerning who reports to the Board for the Plan and what reports are submitted. Furthermore, the Program Description does not accurately describe the monitoring of Potential Quality Issues and later only vaguely mentions its review as a function of the Quality Improvement Committee.


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Rule 1300.70(b)(2)(A) requires that “there must be a written Q[uality] A[ssurance] plan describing the goals and objectives of the program and organization arrangements, including staffing, the methodology for on-going monitoring and evaluation of health services, the scope of the program and required levels of activity.” At the survey, the Plan presented a 2012 Workplan used to track the Plan’s progress in meeting the Plan’s quality assurance goals and functions. Based on this evidence, the Department did not find a violation of Rule 1300.70(b)(2)(A). Rather, the Department found that the Plan failed to include this mechanism in the Plan’s Program Description.

The Plan’s response to Preliminary Report, setting forth its corrective action and objection, failed to submit evidence that its Workplan is incorporated into its description, or that it has a monitoring function in place to evaluate the Plan’s overall progress in meeting its yearly quality assurance goals. Therefore, the Department finds the Plan has not corrected this deficiency. At the Follow-Up Survey, the Department will assess whether the Plan’s mechanism for monitoring its overall progress towards meeting its quality assurance goals is included in the Plan’s Quality Assurance Program Description.

Based upon the corrective actions undertaken, the Department has determined that the Plan has not fully corrected this deficiency.

Deficiency #5: The Plan’s Quality Management Program is not adequately

directed by an appropriate provider/clinician, nor does it ensure that there is sufficient administrative and clinical staff support to carry out quality assurance activities for the Plan and the Plan’s delegated entities.

Statutory/Regulatory Reference(s): Rules 1300.70(b)(2)(D) through (F)

Assessment: The Plan lacks adequate clinical supervision to meet its quality assurance obligations. Of significant concern, the Department found evidence that clinical involvement in Plan operations was insufficient in a number of deficiencies:

• A number of processes are inconsistently performed, e.g., the identification, investigation and correction of quality of care issues;

• Policies and procedures need to be developed or updated; and • Clinical involvement and coordination with the grievance process has been

lacking.

Further, although the Dental Director Job Description identifies the Dental Director as the person responsible for providing clinical direction to the Quality Management Program, the Department found that other non-clinical staff members were performing some activities that the clinical staff should perform.

The Blue Cross Quality Improvement Workplan, 2012, provides that the Compliance Manager oversees the Quality Assurance Systemic Report, and will “work with poor


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performing providers to improve member satisfaction and clinical performance.” The Compliance Manager is also expected to conduct oversight of potential quality of care issues, and to “monitor for potential quality problems and elevate to Quality Improvement Committee if warranted.” However, the Compliance Manager does not have the clinical qualifications necessary to adequately perform these duties consistent with Rules 1300.70(b)(2)(E) and (F).

Industry standards require oversight by the Dental Director or another dentist in performing these functions. The same document reports that the Clinical Quality/Compliance Administrator is responsible for oversight of Provider Audits (onsite provider chart and facility reviews) to “audit providers according to the Quality Assurance Program specifications.” The Department finds that the Clinical Quality/Compliance Administrator does not have the clinical qualifications to perform these duties.

Rule 1300.70(b)(2)(D) requires that “the Quality Assurance Program … be supervised by a designated dentist.” Rule 1300.70(b)(2)(E) requires that a licensed “dentist … participation in QA activity must be adequate to monitor the full scope of clinical services rendered, resolve problems and ensure that corrective action is taken when indicated.” Rule 1300.70(b)(2)(F) further requires that plans have “administrative and clinical staff support with sufficient knowledge and experience to assist in carrying out their assigned QA activities for the plan and delegated entities.” Because the Plan failed to ensure sufficient participation from the Dental Director or other dentists, the Department finds it in violation of Rules 1300.70(b)(2)(D) through (F).


Plan’s Compliance Effort: The Plan stated that since July 21, 2014, the Plan has hired and maintained a full-time California Dental Director. To ensure that the Plan meets its quality assurance obligations, the Dental Director reviews all grievances to determine whether they are quality of care or quality of service issues. The Dental Director defines both exempt and non-exempt grievance categories of which Customer Service Representatives and Grievance and Appeal Analysts use for classification, and staff are directed to request assistance from the Dental Director if needed. The exempt (Category II) grievance review process performed by Customer Service Representatives now involves the Dental Director or his/her clinical assignee to review Category II grievances for correct category assignment. Non-exempt grievances (Category I) are reviewed by the Grievance Committee and these meetings are attended by the Dental Director or a licensed dentist. For non-exempt grievances, the clinician reviews the grievance case file to identify potential quality issues and determines a severity rating.

The Dental Director receives all potential quality issues and develops a corrective action plan. The Plan sends corrective action letters to providers for failure to submit records, failure to follow specialty referral guidelines, treatment plan and financial irregularities, balance billing of members, requests for office written policies regarding specialty referrals and financial arrangement policies. Additionally, the Plan sends corrective


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action letters for refunds for inappropriate charges for endodontic irrigation and laser bacterial recontamination, correction of current dental terminology coding and requested radiographic exposure policy and amalgam safety policy along with treatment planning. The Dental Director conducts oversight of potential quality issues and elevates them to the Quality Improvement Committee.

To provide assistance for the Dental Director, the Plan’s Compliance Manager provides administrative support for Plan oversight of potential quality issues, and prepares the grievance systemic report flagging potential quality issues for the Dental Director to review. In addition, the Compliance Manager prepares the potential quality issues watch list as identified by the Dental Director. The Plan’s Clinical Quality Compliance Administrator schedules provider and facility audits and enters data into a database after the Dental Director has reviewed provider and facility audits. All non-clinical staff, including the Compliance Manager and the Clinical Quality Compliance Administrator merely provides administrative assistance in organizing and processing of data for Dental Director’s review.

Quality Assurance Chart and Facility Audits:

The Dental Director reviews audit results to formulate corrective action plans and analyze data for trends and patterns, and reports the findings to the Dental Quality Improvement Committee. The Dental Director monitors the adequacy of staff to support the audit function and administrative staff to facilitate clerical follow-up such as:

• Monitors audit results and generates corrective action letters for offices scoring below thresholds at the direction of the Dental Director.

• Corrective action letters require a response from the office as to their corrective action plan. Dental Director reviews the response for appropriateness. Further action is taken as needed.

• Letters to higher scoring offices also contain recommendations for correction of minor issues.

• Audit results are accumulated on a spreadsheet, which is used to generate corrective action letters.

• Determine the audit frequency from findings. For instance, scores above 90% are audited every three years. Scores in the 70% are audited more frequently.

• Results of audits are reported to QIC for recommendations.


Based upon the corrective actions undertaken, the Department has determined that the Plan has been corrected this deficiency.


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Deficiency #6: The Plan’s governing body does not receive reports that are sufficiently detailed to include findings and actions taken as a result of the Quality Assurance Program, and that identify those internal or contracting provider components that the Quality Assurance Program has identified as presenting significant or chronic quality of care issues.

Statutory/Regulatory Reference(s): Rule 1300.70(b)(1)(A); Rule 1300.70(b)(2)(C)

Assessment: The Plan is a division of Blue Cross of California dba Anthem Blue Cross, owned by WellPoint, Inc. As such, the Plan reports to the Anthem Blue Cross governing Board. On a quarterly basis, the Plan’s Director of Claims Review provides a PowerPoint presentation titled Dental HMO Report to the Board. This report consists of the following nine slides, each updated with current data to present at each quarterly Board meeting:

1. Quality Improvement Access Report: three bullet points listing the number of providers to members, the percentage of members with desired provider access, and the number of access issues for the quarter.

2. Access: a bar graph displaying number of members and providers by quarter, 2006 to the present.

3. Participating Providers: a bar graph displaying the number of general and specialist participating dentists for the last three quarters.

4. Grievance and Consumer Complaints: three bullet points listing the grievance level per 1,000 members, the number of consumer complaints to the Department, and the percentage of grievances closed within 30 days.

5. Grievance Time Frames: a bar graph displaying the percentage of grievances closed within 30 days, by quarter, 2007 to the present.

6. Grievance Report by Reason: a bar graph displaying total and type of grievances logged by quarter, 2009 to the present, categorized as coverage disputes, medical necessary, quality of care and service, accessibility, and other.

7. Grievance Report by Resolution: a bar graph displaying the percentage of grievance resolutions found in favor of the Plan vs. members, by quarter, 2007 to the present.

8. Specialty Referral Time Frames: a bar graph displaying the percentage of referrals to specialist providers that were closed within 30 days by quarter, 2007 to the present.

9. Capitation and Claims (percent of premium): a bar graph displaying the percentage of capitation and claims paid compared to premiums received, by quarter, 2007 to the present.

Overall, the dental presentation to the Board contains no detailed findings and lacks documentation of the actions of the Quality Assurance Program. It fails to help the Board identify issues that might present significant or chronic quality of care problems. The information presented in these nine slides is very broad, representing general network issues and provides the Board with little information on Quality Management Program activities and quality issues. Notably, the types of grievances that are reported, but the category most pertinent to quality management—the quality of care grievances—is combined with quality of service grievances and reported as a single


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number, which makes it impossible to distinguish quality of dental treatment issues from quality of service issues.

The Plan does not submit detailed Quality Improvement Committee activity reports to the Board for review and discussion. The Board also does not consistently receive information on: (1) provider site audit results or (2) the Plan’s investigation of Potential Quality Issues (PQIs), two primary components of the Plan’s provider quality oversight.

The Department interviewed the Director of Claims Review who reported that the presentation takes a few minutes and typically does not generate any questions from the Board. The Dental Director, who does possess the clinical background does not attend the presentation and reported that he does not communicate directly with the Board regarding any quality issues. Moreover, even if there were questions, the presenter of the Report to the Board, the Director of Claims Review, does not have the clinical background or qualifications to answer the Board’s questions regarding problems or failures of the Plan’s quality of care processes.

As a result of insufficient information and inadequate reporting to the Board, there is no meaningful discussion or analysis of quality issues recorded in the Board Minutes. The minutes do not reflect Board recommendations and/or directions to the Quality Improvement Committee. The minutes have a routine entry for the dental plan that is two sentences long:

“The Director of Claims Review presented the Dental HMO Report for the period ending …, and distributed a copy to the Board prior to the meeting. Following discussion and upon motion duly made and seconded, the Board accepted the Dental HMO Report as presented.”

There is insufficient evidence of the Board’s leadership role in ensuring that the Plan is delivering care meeting professionally recognized standards of practice to all enrollees.

Rule 1300.70(b)(1)(A) requires that “each plan's Quality Assurance Program be designed to ensure that a level of care which meets professionally recognized standards of practice is being delivered to all enrollees.” As one activity in meeting this obligation, Rule 1300.70(b)(2)(C) requires that each of the Plan’s governing body meet at least “quarterly … to oversee Quality Assurance Program responsibilities.” The Rule further requires that “[r]eports to the governing body … be sufficiently detailed to include findings and actions taken as a result of the Q[uality] A[ssurance] program and to identify those internal or contracting provider components which the Quality Assurance Program has identified as presenting significant or chronic quality of care issues.” Because no detailed findings and actions of the Quality Assurance Program were presented in reports to the Board and because the reports failed to identify issues that present significant or chronic quality of care problems, the Department finds that the Plan failed to meet the requirements of Rule 1300.70(b)(1)(A) and Rule 1300.70(b)(2)(C).



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Plan’s Compliance Effort: The Plan stated that “Since June 18, 2013 the California Dental Director has attended all quarterly Board of Director’s meetings and made the presentation(s) on behalf of Dental.” The Plan confirmed that Quality Improvement Committee minutes, including details on grievances, are incorporated into the quarterly reports presented to the Board. The Plan also stated that the dental report includes a quality assurance report. As part of its corrective action, the Plan included an example of the Dental Director’s presentation at the most recent Board meeting.

In response to the Department’s concern that the types of grievances are reported, but the category most pertinent to quality management – the quality of care grievances – is combined with quality of service grievances and is reported as a single number, the Plan stated that “many reports to the Board have been enhanced. The grievance report now includes Quality of Care and Quality of Service as separate categories. The Plan included an illustration of the new Board PowerPoint presentation slides showing Quality of Care and Quality of Service separated out.

The Plan also noted that its report “currently reflects: (1) at each quarterly Board meeting, dental presents a summary of provider office audits performed. In addition, corrective action letters are sent to those providers whose scores show trending of concern, specifically repeated unsatisfactory responses in any given audit category, who score unsatisfactory on critical issues, or whose total scores drop below expected results. QA actions may include recommendations even when the overall score is satisfactory, requests of policies and procedures, and requests for corrective action in specific areas of deficiency, and (2) the PQI process has been enhanced as demonstrated in corrective action identified in QIC minutes.” The Plan included examples of the Quality Improvement Committee minutes.


As evidence of improved reporting, the Plan submitted only one quarterly report to the Board presented at the Third Quarter 2014 meeting held December 8, 2014, and two slides from the Fourth Quarter 2014 meeting held March 12, 2015. The Plan submitted minutes for only one Board meeting, the Third Quarter 2014 meeting. These minutes provide no detail on any information provided verbally by the Dental Director or on any discussions by the Board. The minutes simply state:

The Dental Director presented the Dental HMO Report for the period ending September 30, 2014, and distributed a copy to the Board prior to the meeting. Following discussion and upon motion duly made and seconded, the Board accepted the Dental HMO Report for the period ending September 30, 2014 as presented.

The Department finds that the Plan has enhanced the detail in its report to the Board and has included its California Dental Director in Board meetings to discuss Quality Assurance Activities. However, there is insufficient evidence that the reports provided the Board sufficient detail and served to “identify those internal or contracting provider components which the QA program has identified as presenting significant or chronic quality of care issues” as required by Rule 1300.70(b)(2)(C).


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For example, the Quality Improvement Committee minutes for September 2014, reflect a concern with the increasing number of quality of care and services grievances:

The Compliance Manager explained the majority of grievances were coverage disputes or financial issues. The Senior Clinical Quality/Compliance Administrator informed the committee that 63% of the grievances were quality of care or quality of service related. A Board Member wondered why there was such a large increase in the quality of care and services. The Compliance Manager stated the majority of the grievances concerned provider charges and/or upgrades.

The two slides from the Fourth Quarter 2014 Board meeting DHMO Grievance by Reason Counts reflect the increased counts of quality of service grievances. However, the slides do not identify this increase as an issue of concern nor do they provide any further explanation or discussion of findings, root causes, or actions taken. Because the Plan did not submit Board minutes for this meeting, there is no evidence that the Dental Director identified this significant increase verbally for the Board’s consideration or provided additional information. There is also no evidence that the Board used the reports to “oversee their respective QA program responsibilities” as required by Rule 1300.70(b)(2)(C).

Such oversight was not apparent from review of minutes from the subsequent Quality Improvement Committee meeting. The Plan’s Quality Improvement Committee meeting minutes for Fourth Quarter 2014 (held April 23, 2015), again notes this potentially significant issue but makes no mention that the Board had provided oversight (e.g., requested additional information/ investigation, provided direction) from its March 2015 meeting:

Committee member wondered about the increase in the number of quality of service grievances. The Compliance Manager explained quality of service could be coverage disputes depending upon the circumstances. Overcharges were one of the factors regarding the increase in quality of service in this quarter’s categorization. The Dental Director informed the committee that 40% of the grievances were resolved in favor of the provider or plan. Grievance Recap Analysis reflects a 9% increase of grievances received with 8% decrease in membership within the current quarter compared to third quarter last year.

As noted above, the degree of detail in the one Board report that was, submitted (Anthem Blue Cross Dental HMO Report Third Quarter 2014) has improved from the time of the Department’s onsite visit. However, for some topics it appears that numbers are provided, but without sufficient context or interpretation (e.g., the report shows that five providers were terminated but does not explain the reasons for terminations). Moreover, the Department is concerned that other key topics relating to quality (e.g., quality improvement projects/studies, potential quality issues other than audit findings) do not appear to have been addressed at all. These issues may have been discussed, but due to the absence of detail in the Board minutes, there was no evidence that this occurred.


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Finally, although the Plan’s response was dated July 17, 2015, the Plan presented only one quarterly report to the Board – Third Quarter 2014. The Plan stated in its response regarding this report that it “is the Dental Director’s presentation at the most recent Board meeting.” However, there was a more recent Fourth Quarter Board meeting held on March 12, 2015 (as evidenced by the two slides from that meeting). The complete report presented at that meeting was not submitted. Given that the Plan only submitted one report, it did not demonstrate that reporting improvements are consistent and sustained. Therefore, in order to provide the Plan with additional time to the Department will conduct additional review at the Follow-Up Survey.

Based upon the corrective actions undertaken, the Department has determined that this deficiency has not been fully corrected.

GRIEVANCES AND APPEALS

Deficiency #7: The Plan does not fully address the requirements for the online grievance submission process. Specifically, the Plan’s online grievance process does not: • Include a hyperlink on the home page or member services

portal clearly identified as “GRIEVANCE FORM” ; and • Include the Department’s paragraph as required by Section

1368.02(b).

Statutory/Regulatory Reference(s): Section 1368.015; Section 1368.02(b)

Assessment: During the onsite visit, the Department viewed a presentation of the Plan’s online grievance submission process provided by a Plan Grievance and Appeals Coordinator, who logged into the system under her membership number. In this way, the Department was able to observe the online process through the member portal as any Plan member would view it when submitting a grievance. The Plan’s online grievance submission process does not allow the grievant/ complainant to preview and edit the grievance form prior to submission, nor does it contain the mandatory paragraph from Section 1368.02(b) that advises enrollees of grievance rights and the Department’s contact information, including a hyperlink to the Department’s web site.

Upon completion of the member login process by the Plan presenter, the Department surveyor asked her to proceed to the hyperlink marked, “File a Grievance or Appeal,” located in the menu on the left of the screen, which was not labeled “GRIEVANCE FORM” in all capital letters as mandated under Section 1368.015(b). The hyperlink revealed the online grievance form.

The online grievance form web page did not contain a current hyperlink to the California Department of Managed Health Care website and a statement that contains the required language from Section 1368.02(b). The Plan presenter acknowledged this deficiency. Upon further investigation, the surveyor found the hyperlink to the Department and the required language statement elsewhere in the Grievance and Appeal sub-section of the FAQ section, which is accessed through the member portal. Plan staff stated to both the Department surveyor and Department team lead that this


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was a corporate Web site and as such, the Plan was unable to change the format at this time.

Additionally, the Department surveyor reviewed screen shots (undated document titled “How to File an Electronic Grievance”), which the Plan submitted to show the online grievance process, and was unable to locate the hyperlink or required language statement in those screen shots.

Section 1368.015(b) requires the Plan to provide an online grievance submission form accessible via a hyperlink identified as, GRIEVANCE FORM. The Plan is also required to include the statement that contains the language from Section 1368.02(b) within the grievance form. Because the Plan’s website does not contain a hyperlink to the grievance form in the proper format and because the grievance form does not include the required language from Section 1368.02(b), the Department finds the Plan in violation of Section 1368.015(b) and Section 1368.02(b).

Corrective Action: Within 45 days following notice of a deficiency, the Plan is required to file a written statement with the Department signed by an officer of the Plan, describing any actions it has taken to correct the deficiency.

Plan’s Compliance Effort: The Plan represented that it was able to modify the existing online grievance process to allow members to review and edit the grievance form prior to submission, include a web link to the Plan’s grievance forms, and a link to filing an online grievance. Additionally, the Plan stated that its links to its grievance forms and link to the online grievance form are labeled in bold upper case font and that those forms include the Department’s paragraph as required by Section 1368.02(b).


The Plan failed to provide a login in to assess the Plan’s Member Portal; therefore, the Department reviewed the Plan’s public online grievance process for compliance. The Department was unable to confirm that the Plan’s online grievance process allows the grievant/complainant to preview and edit the grievance form prior to submission. Additionally, the Department could not confirm that the online grievance form contained the Department’s mandatory paragraph from Section 1368.02(b), which advises enrollees of grievance rights and Department’s contact information. Notably, the screen shots provided by the Plan failed to include this paragraph.

Based upon the corrective actions undertaken, the Department has determined that the Plan has not fully corrected the deficiency.

Deficiency #8: The Plan does not consistently acknowledge enrollee grievances

and appeals in writing within five calendar days of receipt, nor does it consistently include the date the Plan received the grievance within the written acknowledgment letter.


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Statutory/Regulatory Reference(s): Section 1368(a)(4)(A); Section 1368(a)(4)(A)(ii) and Rule 1300.68(d)(1)

Assessment: The Department’s file review found that the Plan does not consistently acknowledge grievances and appeals in writing within five (5) calendar days of receipt as required by Section 1368(a)(4)(A) and Rule 1300.68(d)(1). Additionally, the Department’s file review found that the Plan does not consistently include the date of receipt in the acknowledgment letters as required by Section 1368(a)(4)(A)(ii) and Rule 1300.68(d)(1).

1. The Department identified the following concerns with regards toacknowledgment of enrollee grievances:

a. Written and Oral Grievances

In 24 of the 49 standard grievance cases (49%) reviewed, the Plan failed to acknowledge the grievance within this required timeframe. Notably, the Plan received 10 of the 49 grievances in writing.

b. Written Grievances

The Department found that in five (5) of the 10 (50%) written grievances reviewed, the Plan failed to acknowledge the grievance within five calendar days of receipt.

The Plan indicated that a previously distributed Evidence of Coverage (EOC) directs enrollees to submit written grievances to a P.O. Box address. A vendor then opens the mail and forwards written grievances to the Plan. During interviews, Plan staff stated that they record the receipt date of the written grievance, as the day the Plan receives the grievance letter from the vendor, not the day the vendor receives the grievance letter from the enrollee.

2. The Department identified the following concerns with regards to inclusion ofthe date of receipt of a grievance within its acknowledgment letters:

In 33 of the 49 (67%) standard grievance files reviewed, the Plan failed to notify the grievant in the acknowledgement letter, of the date the Plan received the grievance. The Department noted that the Plan does not use a template acknowledgement letter, which may contribute to the Plan’s inconsistency in including the grievance receipt date in some letters and not others.

Section 1368(a)(4)(A) and Rule 1300.68(d)(1) require each plan to respond to grievances by providing a written acknowledgment within five calendar days of receipt of the grievance by the Plan. Under Section 1368(a)(4)(A)(ii) the acknowledgment must advise the complainant of the date of receipt, and provide the Plan representative's name, telephone number and address to contact about the grievance. Because the

Department found from its file review that the Plan did not consistently send acknowledgement letters within the required five day timeframe and did not consistently include the date the Plan received the grievance in those acknowledgement letters, the


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Department finds the Plan in violation of Section 1368(a)(4); Section 1368(a)(4)(A)(ii) and Rule 1300.68(d)(1).

TABLE 3Grievance File Review

FILE TYPE NUMBER

OF FILES

ELEMENT COMPLIANT DEFICIENT

Standard Grievance 49

Acknowledgement letter sent within five calendar days of receipt

25 24

Standard Grievance 49

Acknowledgement letter includes receipt date of grievance

16 33


Plan’s Compliance Effort: The Plan has implemented a process to ensure the receipt date of grievances is the initial date of contact by the Plan of the grievance letter received. Grievance and appeals processes now reinforce that the receipt date of grievance recorded is the initial date of contact by the Plan and that the date must be included within all acknowledgment letters mailed within five calendar days of initial date of contact unless grievance can be resolved within five days. To ensure compliance, the Dental Director on a monthly basis reviews the Plan’s grievance log, which includes receipt date of grievance as well as mailing date of the acknowledgment letter.

The Plan has established an audit process for reviewing the handling of grievances by Plan staff. This audit system includes a monthly review of a random selection of cases by grievance and appeals staff leads. In each audit, the leads review timeliness and accuracy of acknowledgement letters.


Based upon the corrective actions undertaken, the Department has determined that the Plan has not corrected this deficiency. While the Plan has implemented processes to ensure that it records the receipt date of the grievance as the initial date of contact by the Plan, and has implemented an audit process to ensure timeliness and accuracy of acknowledgement letters, the Plan has not provided sufficient proof of implementation or the effectiveness of the improved process. During the Follow-Up Survey, the Department will review the Plan’s grievance audit results and assess the Plan’s compliance through file review.


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Deficiency # 9: The Plan does not fully address the requirements for expedited review of urgent grievances in its written policies and procedures. Specifically, the Plan’s procedures do not provide for: • Plan response to the Department’s contacts/communications

regarding urgent grievances 24 hours a day, 7 days a week;• the scheduling of qualified Plan representatives, including

back-up Plan representatives as necessary, to be available24 hours a day, 7 days a week;

• notification to the Department at least 30 days in advance ofimplementing revisions to the urgent grievance system; and

• Plan response to the Department within 30 minutes afterinitial contact from the Department during normal workinghours and within one hour during non-working hours.

Statutory/Regulatory Reference(s): Rules 1300.68.01(a) and (b); Rule 1300.68.01(b)(2)(A)

Assessment: The Department reviewed the Plan’s policies and procedures relevant to urgent grievances and appeals. The sole mention of urgent grievances in the Plan policies and procedures is contained in the Anthem Blue Cross Grievance Resolution Criteria and Standards document last amended on January 13, 2010. This document states:

[The Plan] shall have expedited review of grievances for cases involving an imminent and serious threat to the health of the patient, including but not limited to loss of life, limb, or major bodily function. In cases of expedited review, the grievance system shall immediately inform the enrollee or subscriber of their right to notify the Department of Managed Health Care of the grievance. In these expedited review cases, plan shall provide the enrollee or subscriber and the Department a written statement on the disposition or pending status of the grievance no later than five (5) days from receipt of the grievance. The explicit criteria for appropriate identification by member services staff of grievances, which require expedited review, are defined as imminent and serious threat to the health of the patient, including but not limited to loss of life, limb, or major bodily function.

Plan policy does not provide for the Plan to receive Department contacts/communications regarding urgent grievances 24 hours a day, 7 days a week as required by Rule 1300.68.01(b). The Plan does not schedule qualified Plan representatives, including back-up Plan representatives, as necessary, to be available 24 hours a day, 7 days a week as required Rule 1300.68.01(b)(1). The policy does not require the Plan to notify the Department at least 30 days in advance of implementing revisions to the urgent grievance system, a requirement established pursuant to Rule 1300.68.01(b)(2)(B)(3). Finally, Plan policy does not require the Plan to respond to the Department within 30 minutes after initial contact from the Department during normal working hours and within one hour after initial contact from the Department during non-working hours as required by Rule 1300.68.01(b).


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The Plan was unable to provide any documentation prior to, or during the survey, that indicates the Plan has working policies and procedures to address these issues regarding urgent grievances. During interviews, the Plan’s Compliance Manager stated that, “The State knows to call the corporate office for urgent grievances.”

Rule 1300.68.01(b) requires each plan to have provisions to respond to Department contacts “regarding urgent grievances 24 hours a day, 7 days a week.” Rules 1300.68.01(b)(1) and (b)(2)(A) require the Plan to have available a representative, and a back-up representative, with authority to resolve grievances and authorize the provision of health care services during and after business hours within specific timeframes. Because the Department found from its review of Plan documents and confirmed in subsequent staff interviews, that the Plan has not included these elements in its policies and procedures on the subject of urgent grievances, the Department finds the Plan in violation of Rules 1300.68.01(b) and (b)(1).

Rule 1300.68.01(b)(2)(A) requires each plan to provide the Department with a description of the system established by the Plan to resolve urgent grievances. The description shall include the system's provisions for scheduling qualified Plan representatives, including back-up Plan representatives as necessary, to be available twenty-four (24) hours a day, seven days a week to respond to Department contacts. Provisions for scheduling shall include the names and titles of those Plan representatives, their telephone numbers, and, as applicable, pager numbers, answering service numbers, voice-mail numbers, e-mail addresses, or other means for contact. Because the Plan has not provided this description, the Department finds it in violation of Rule 1300.68.01(b)(2)(A).

The Department reviewed the Plan’s Urgent Grievance Log, which indicated that the Plan had not received any urgent grievances during the period November 1, 2010 to October 31, 2012. However, should a grievance requiring expedited review be filed, the Plan has inadequate policies and procedures in place to ensure that it can address the issue appropriately and within required timeframes.


Plan’s Compliance Effort: As part of its corrective action, the Plan has provided an internal policy and procedure for expedite review of urgent grievances. Plan policy now states that the Dental Director is available to respond to the Department 24 hours a day, seven days a week. The Dental Director will have the ability to make decisions on behalf of the Plan. Plan policy also states that during regular business hours, the Dental Director will respond to the Department within 30 minutes of receiving the call from the Department and after regular business hours, the Dental Director will respond to the Department within 1 hour of receiving the call from the Department. Finally, Anthem’s policy states that the Plan will notify the Department at least 30 days in advance of implementing changes to the urgent grievance system.



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Based upon the corrective actions undertaken, the Department has determined that the Plan has not fully corrected this deficiency. The Plan must include a backup representative in case the Dental Director is not available, as required by Rules 1300.68.01(b)(2)(A). To ensure compliance with the Act, the Plan’s policy regarding urgent grievances, including Plan contact information, must be filed with the Department’s Division of Licensing upon being approved by the Plan pursuant to Section 1368(a)(1), Section 1368.01(b) and Rule 1300.68.01(b)(2)(A).

ACCESS AND AVAILABILTY OF SERVICES

Deficiency #10: The Plan does not have a documented system for monitoring and evaluating accessibility of care, including a system for addressing problems that develop, which shall include, but is not limited to, waiting time and appointments.

Statutory/Regulatory Reference(s): Rule 1300.67.2(f); Rule 1300.67.2.2(d)

Assessment: The Plan’s primary method for monitoring appointment wait times is through administration of a telephone survey to 50 randomly selected providers per quarter6. The survey collects information on after-hours availability, appointment wait times, and in-office wait times (e.g., “Can the Office respond to urgent situations within 72 hours?” “Can you tell me when your next available appointment is for a routine examination?” “When is your next available Hygiene appointment?)” The Plan compares the results with its standards and with appointment wait time limitations and other standards established by Rule 1300.67.2.2.

1. The Plan’s survey methodology does not ensure that timely access to care is adequately monitored.

The Plan began administering the survey in the 1st quarter of 2012 and had administered two surveys at the time the Department conducted its onsite visit. In Quarter 1, 23 of 50 (46%) offices stated they were too busy to take the survey, refused to take the survey, or were closed. In Quarter 2, 19 of 50 (38%) offices were too busy, refused, or closed. Among those providers who responded, compliance rates were high; only three required follow-up for not meeting a standard. The high rate of refusals generates concerns that the results do not accurately reflect appointment wait times throughout the network (e.g., providers who are aware they cannot meet standards may be more likely to decline to take the survey). As a result, the Plan cannot demonstrate that its network overall meets the wait time standards outlined in Rule 1300.67.2.2(c)(6). Additionally, the Plan cannot identify those individual providers who do not meet standards and implement corrective actions to address those problems.

Furthermore, the Plan has not adequately addressed the lack of cooperation from those providers who declined to participate in the survey. The Plan’s contracts with its

6 The Plan also monitors for problems with appointment wait times through its enrollee grievance system; however, because exempt grievances are not regularly analyzed, appointment monitoring through the grievance system is also flawed.


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providers include the requirement that providers participate in the Plan’s Dental Quality Assurance Program. Plan policy includes various disciplinary actions that can be taken for general quality concerns and specifically as follow-up to this survey (e.g., corrective action letters, focused audit, office closed to new members). Nevertheless, although 46% and 38% of providers, respectively, did not take the survey, the Plan conducted no corrective action or follow-up for providers who refused to participate.

Additionally, the Department found that the survey methodology, training, and instructions for staff making the calls, and sampling methodology have not been established in writing, a process that would help to ensure consistency of administration and validity of the resulting data.

Rule 1300.67.2.2(d) requires “[e]ach plan … have written quality assurance systems and policies and procedures designed to ensure the plan’s provider network is sufficient to provide accessibility [and] availability” under standards set forth in Rule 1300.67.2.2(c)(6)7. Rule 1300.67.2(f) requires each plan to “have a documented system for monitoring and evaluating accessibility of care, including a system for addressing problems that develop, which shall include, but is not limited to, waiting time and appointments.” Because the Plan’s approach to monitoring appointment availability has such a high rate of refusal, the Plan cannot demonstrate that appointments are available within the required timeframes. Therefore, the Department finds the Plan in violation of Rule 1300.67.2.2(d) and Rule 1300.67.2(f).

2. The Plan does not ensure that when it is necessary to reschedule an appointment, the appointment is promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs and ensures continuity of care.

Plan policies and procedures do not include a requirement that appointments be rescheduled promptly, nor do they provide guidance for the Plan and its providers to assess promptness of appointment rescheduling. Only the Plan’s Provider Reference Manual addresses this issue by noting that providers are expected to reschedule appointments in a manner that is appropriate to the patient’s health care needs as is required by Rule 1300.67.2.2(c)(3). The Plan’s primary instrument for on-going monitoring of appointment availability—a survey of provider offices—does not contain any items that assess rescheduling. Plan staff acknowledged in interviews that the Plan does not presently conduct any monitoring of the promptness of appointment rescheduling.

Rule 1300.67.2.2(d) requires each plan to have quality assurance systems and compliance monitoring policies and procedures designed to measure accurately the accessibility and availability of contracted providers under standards set forth in subsection (c). Subsection (c)(3) of the same rule requires that, when a provider or an enrollee must reschedule an appointment, the appointment must be promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs and 7 Rule 1300.67.2.2(c)(6) requires each plan to ensure that its contracted dental provider network can offer enrollees urgent appointments within 72 hours of the time of request, non-urgent appointments within 36 business days of the request, and preventive dental care appointments within 40 business days of the request.


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that ensures continuity of care consistent with good professional practice. Because the Plan has not established a methodology for monitoring to ensure prompt rescheduling of appointments, the Department finds the Plan in violation of Rule 1300.67.2.2(d).

The Department notes that the Plan received a deficiency during its 2010 Routine Survey for not having “an adequate system for monitoring and evaluating accessibility of care, including a system for addressing problems that develop, which shall include, but is not limited to, waiting times and appointments.” Part of the corrective action for that survey involved secret shopper calls to assess appointment wait times and in-office wait times. The Plan discontinued those calls on an unknown date and without notifying the Department. The Plan later replaced the secret shopper process with a telephone access survey.


Plan’s Compliance Effort:

1. The Plan’s survey methodology does not ensure that it adequately monitors timely access to care.

The Plan implemented policies and procedures for monitoring and evaluating accessibility of care, in addition to surveying providers related to access and availability. The Plan tracks access to care in several ways, including but not limited to: determining ratio of primary care dentists and specialists to enrollees, upon initial procedural audit, upon formal chart audit, grievance tracking, onsite accessibility survey, and through quarterly Geo Access reports.

If a provider does not meet access standards, the Dental Director initiates corrective action and subsequently reports to the Quality Improvement Committee. Corrective action may include dentist-to-dentist phone calls, corrective action letter, follow-up by onsite focused audit, as well as closing office to new members, notice of contract violation and due process, and termination from the network.

Additionally, the Plan modified its survey methodology to incorporate an onsite survey, supported by an enhanced telephone survey performed by Plan staff. The process ensures that the necessary information is obtained and documented with respects to performance of provider offices. The Plan attested that since the revision, no participating dentists have declined to provide the access information required. In addition, when performing the onsite survey, the Network Management Representative also checks the appointment book to confirm appointment availability.

2. The Plan does not ensure that when it is necessary to reschedule an appointment, it reschedules the appointment promptly in a manner that is appropriate for the enrollee’s health care needs and ensures continuity of care.


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The Plan added appointment rescheduling to the data collected in its access survey tool to enable the Plan to determine whether further action is required as appropriate to ensure compliance with prompt rescheduling of appointments, including additional audits of the providers, increased monitoring, or implementation of corrective actions. The Plan provided a copy of this audit tool reflecting this change.


Based upon the corrective actions undertaken, the Department has determined that this deficiency has been fully corrected.

UTILIZATION MANAGEMENT

Deficiency #11: In the Plan’s written communications to enrollees and providers regarding decisions to deny or modify health care services based on dental necessity, the Plan does not consistently provide or include: • a clear and concise explanation of the reasons for the Plan’s

decision; • a description of the criteria or guidelines used; • the clinical reasons for the decisions; • a licensed health care professional evaluated the clinical

issue involved; and • the name and direct telephone number or extension of the

health care professional responsible for the denial or modification in its written response to providers.

Statutory/Regulatory Reference(s): Section 1367.01(h)(4); Section 1386(b)(1)

Assessment: The Department’s review revealed 40 of 42 claims8, that were retrospectively denied based on dental necessity, did not consistently include a clear and concise explanation of the reasons for the Plan’s decision as required by Section 1367.01(h)(4) and per Plan policy regarding the Notification of Delays in Utilization Management Review9. A total of 39 of the 42 claims reviewed did not contain a description of the criteria or guidelines used, or the clinical reasons for the decisions regarding dental necessity. The Department also found that 34 of these communications did not consistently include the name and direct telephone number or an extension of the health care professional responsible for the denial or modification as required by Section 1367.01(h)(4) and as required per Plan policy regarding the Notification of Delays in Utilization Management Review.

The Plan uses the Explanation of Benefit (EOB)—a written statement explaining how and why a claim is paid or denied by the Plan—as a means to communicate the 8 The Department randomly selected 78 denied claims from a universe of 29,368 claim denials. However, only 42 files were denied based on dental necessity. Twenty-eight were denied based on the enrollee’s benefit coverage/limitations and exclusions. One was denied for untimely filing (i.e., claim was filed beyond the allowed time period for submitting claims). One was denied for lack of required authorization. One was denied for an unknown reason (the EOB was missing). Five were approved claims 9 Notification of Delays in UM Review Policy Approval Date: September 14, 2012.


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reasons for denying dental services. For each processed claim, the Plan issues its EOB to both the provider and the enrollee. The Plan issued an EOB for each of the 42 claims denied based on dental necessity. Each EOB contained a numerical and/or alpha “remark code,” which has (or should have) a corresponding written description that describes the reason for the denial.

1. Clinical Criteria or Guideline and Clinical Reason Section 1367.01(h)(4) requires “[r]esponses regarding decisions to deny, delay or modify health care service requested by providers … include … a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.”10 Thirty-nine (39) EOB did not specify the criteria or guidelines used and the clinical reason for the Plan’s decision.11

2. Review by a Licensed Health Care Professional Section 1367.01(e) only allows “a licensed health care professional who is competent to evaluate the specific clinical issues involved may deny or modify requests for authorization of health care services for an enrollee for reasons of medical necessity.” Of the 42 claim denials, only eight of the EOBs showed evidence that a qualified licensed professional reviewed the claims and rendered the decision to deny.

3. The Name and Direct Telephone Number or Extension of the Health Care Professional Responsible for the Denial or Modification Section 1367.01(h)(4) requires “[a] Any written communication to a physician or other health care provider of a denial, delay, or modification of a request shall include the name and telephone number of the health care professional responsible for the denial, delay, or modification.”12 Thirty-four (34) EOBs did not contain the name and telephone number of the licensed professional who was responsible for the denial decision.

3. Clear and Concise Section 1367.01(h)(4) requires “[r]esponses regarding decisions to deny, delay or modify health care service requested by providers … include a clear and concise explanation of the reasons for the plan’s decision … .”13 Six EOBs contained only remark codes with no descriptions.14 Of the 36 EOBs with remark code descriptions, only two contained remark codes with clear descriptions of the reasons for the denials.

In review of the thirty-six (36) EOBs, the Department found that the remark code descriptions are often vague and misleading. Further, some contain language

10 See also paragraph 4 of Notification of Delays in UM Review (Policy Approval Date September 14, 2012) requiring that decisions made based upon dental necessity include a description of the criteria or guidelines used, and the clinical reasons for the decisions. 11 One file (Claim #14) did not need to specify the criteria or guidelines used and/or the clinical reason for the Plan’s denial. 12 See also paragraph 4 of Notification of Delays in UM Review (Policy Approval Date September 14, 2012) requiring that decisions made based upon dental necessity include the name and telephone number of the health care professional responsible 13 See also paragraph 4 of Notification of Delays in UM Review (Policy Approval Date September 14, 2012) requiring that decisions made based upon dental necessity be clear and concise. 14 Plan staff explained that EOBs with no corresponding descriptions are “glitches in the claims system”, which the Plan had started to correct with the Information Technology Department. It is unknown whether this system anomaly has been fully corrected.


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inappropriate for, or not easily understood by lay readers/enrollees15. The following are examples of remark codes with unclear descriptions:

Remark Code/Description Reason Why Code/Description Is Unclear

Code: 898: The plan pays amount based on the benefit schedule in your policy. No additional payment made for select HMO plans. Please contact your contracting dental office for any balance due.

Code 898 is the most commonly used remark code. Plan staff indicated they use this code when the provider's capitation fee covers the service rendered, and, therefore, no additional payment is due. The last statement “Please contact your contracting dental office for any balance due” leads the reader/enrollee to believe that s/he may owe the provider monies and may lead to inappropriate provider billing or collection of monies from enrollees.

Code: 3G: What’s not covered and limited services. Please refer to your certificate of coverage at the following location for additional information.

Code 3G provides an explanation in vague language. It does not explain what is not covered and why it is not covered.

Code: 750: Non-pathological third molar extractions are excluded from the plan.

Code 750 describes dental/medical terms that are not appropriate for lay readers/enrollees, as they will likely not understand them.

Code: 715: The submitted radiographs are inadequate and/or non-diagnostic.

Code 715 provides the explanation in vague language and does not explain why the radiographs are inadequate.

Code: 706: Radiographic evidence and/or narrative documentation do not meet established endodontic specialty referral criteria of calcified roots, severe curvature of roots, or extraordinary difficult access.

Code 706 describes dental/medical terms that are not appropriate for lay readers/enrollees, as they will likely not understand them.

Of the 42 denial claims reviewed, 70% contained Code 898. Plan staff stated in interviews during this and past Surveys that the Claims Department uses this code when a claim is submitted as an encounter form.16 The processing of such claims appears to be automatic and built into the claims system. As a result, the Plan 15 In previous Routine and Follow-Up Surveys, the Plan stated that it had reviewed and revised these remark codes to enhance clarity, but despite the Plan’s attempts to clarify the descriptions of the remark codes, the majority of codes noted during the file review remain unclear. 16 An encounter form is a record of an enrollee’s visit to the dental provider, which, when collected regularly and analyzed appropriately, helps the Plan in managing the utilization of services among its enrollees. The plan however does not separate, distinguish, capture, and record these claims as encounters appropriately and accurately, nor does it instruct its providers regarding the proper submission of encounter forms. According to Plan policy, claims submitted as encounter forms must be clearly marked as such with a bold red stamp. However, even those claims clearly stamped as encounter forms were processed as regular claims by the Plan, as noted by the Department.


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automatically generates EOBs to both the enrollees and the providers. However, the last statement “Please contact your contracting dental office for any balance due” is likely to lead the enrollee to believe that s/he may have additional liability for the services rendered and may lead to inappropriate provider billing or collection of monies from enrollees.

The Plan’s staff explained during interviews that it uses remark Code 898 in situations other than collecting encounter data. However, the Department’s assessments of the files revealed the Plan uses this code arbitrarily:

Claim #20: the Plan denied this case involving an oral surgery referral for extraction of third molars with Code 898, despite the presence of authorization, along with appropriate radiographs. Oral surgery is not normally covered under a capitation payment and is customarily billed separately on a fee-for-service basis. The Plan did not indicate a reason as to why it denied the claim. Also of significant concern to the Department, is that the claim file did not show evidence of a licensed professional’s review as required by Section 1367.01(e).

Claim #32: The Plan denied this case involving a periodontal service claim (also not covered under capitation) under Code 898.

Relevant Case Examples: In addition to the deficient claims described above, the following are examples of claims with unclear EOBs:

Claim #12: This claim involved a patient referral for two third molars extractions but the Plan denied the claim with remark Code 515, which states that the teeth are missing or had been extracted. X-rays clearly showed that the teeth were present. There was evidence that a licensed professional had reviewed this claim. When discussed with the Dental Director, he stated that the claim form had the wrong date of service.

Claim #18: This claim involved an endodontic referral, which was denied due to lack of documentation. The Plan eventually paid the claim after receiving all the necessary information. However, a denial remark Code 706 was indicated in the EOB: “Radiographic evidence and/or narrative documentation do not meet established endodontic specialty referral criteria of calcified roots, severe curvature of roots, or extraordinary difficult access.” Additionally, the EOB sent to the provider and enrollee each stated different payment information. The enrollee’s copy stated that nothing was paid, while the provider’s copy stated that $690 was paid. This might have led the enrollee to believe that the provider was not paid, leaving the enrollee responsible.

Section 1367.01(h)(4) requires that “[r]esponses regarding decisions rendered retrospectively to deny, delay, or modify health care services requested by providers … shall be communicated to the enrollee and to the provider in writing.” It also requires that the written communication “shall include a clear and concise explanation of the reasons for the plan’s decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.” The section further requires that “[a]ny written communication to a physician or other health care provider of a denial, delay, or modification of a request shall include the name and telephone number of the health care professional responsible for the denial, delay, or modification.


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The telephone number provided shall be a direct number or an extension in order for the physician or health care provider to easily contact the professional responsible for the denial, delay, or modification.”

Further, the Plan’s policy, Notification of Delays in UM Review (policy approval date September 14, 2012) requires that the Plan’s written notifications to enrollees are clear and concise, contains the criteria or guidelines used and the clinical reasons for the denial and the name and telephone number of the professional who was responsible for the denial decision.

Because the Plan failed to demonstrate that its written responses/EOBs consistently meet this criteria, the Department finds the Plan is not in compliance with Section 1367.01(h)(4). Further, Section 1386(b)(1) provides the following constitutes grounds for disciplinary action: “The plan is operating at variance with the basic organizational documents as filed pursuant to Section 1351 or 1352, or with its published plan, or in any manner contrary to that described in, and reasonably inferred from, the plan as contained in its application for licensure and annual report, or any modification thereof, unless amendments allowing the variation have been submitted to, and approved by, the director.” The Plan is subject to disciplinary action pursuant to Section 1386(b)(1) for its failure to operate in accordance with its policies.

TABLE 4 Claim Explanation of Benefits File Review

FILE TYPE

NUMBER OF

FILES ELEMENT COMPLIANT DEFICIENT

Denied Claims 42

EOB denial notifications contained a clear and concise explanation of the reason for the denial

2 40

Denied Claims 42

EOB denial notifications contained a description of the criteria or guidelines used.

3 39

Denied Claims 42

EOB denial notifications contained the clinical reason for the denial

3 39

Denied Claims 42

Denial file shows evidence of review by a licensed professional

8 34


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Denied Claims 42

EOB denial notifications contained the name and telephone number of the health care professional responsible for the denial of a claim.

8 34


Plan’s Compliance Effort: Since 2013, the Plan implemented monthly Explanation of Benefit (EOB) audits to ensure consistency within its EOBs and to identify any future errors. In addition, the Plan has submitted to the Department revisions to its denial process codes to ensure a clear and concise explanation for the denial, descriptions of criteria or guidelines used, and clinical reasons for the Plan’s decisions.

While the new codes appear to be an improvement over the current denial descriptions, the new codes are still unclear and concise.17 For example, code AP currently states “A review of the records and x-rays provided does not support the type of extraction submitted. Allowance has been made for an alternate benefit.” The new description code proposed states “Documents submitted do not support the extraction billed. An allowance has been made for the correct code.” Neither of these explanations would be clear to a layperson.

As part of its corrective action, the Plan stated that when a licensed health care professional reviews a claim for payment and the specified clinical issues involved, the Plan may deny or modify requests for authorization for reasons of medical necessity, the name and phone number of that reviewer is included on the EOB.

The Plan contends that in all seven of the claims denied for medical necessity, the EOBs included the name and phone number of the licensed health care professional who reviewed the claim18. The Plan asserts that the remaining 35 claims and 17 The Plan requested the Department review and approve the reason codes submitted to correct this deficiency; however, to determine whether the Plan’s explanation of the denial in an individual case is clear and concise the Department reviews each file on a case-by-case basis through its file review. To assist the Plan improving its reason codes in preparation of the Follow-Up Survey the Department conducted a cursory review of the codes and provided. 18 The 42 files reviewed were selected from a log provided by the Plan in response to the Department’s request for a log containing only “medical necessity denials.” (See Appendix A-1 – “Utilization Management (Medical Necessity) Denial and Authorization Modification Log Requirements” sent on 12/4/2012.) The Plan now disputes that the 42 claims selected and reviewed from this log were denied, based in whole or in part, on medical necessity. Specifically, it contends that only seven of the 42 claims it supplied were actually denials based on medical necessity. The Plan stated that of the 42 claims reviewed, many were claims denied with code 898 which is an administrative denial used because the member’s DHMO plan does not provide any claims based reimbursement or cost for all services are covered by the capitation and/or copay. However, the Department notes that six of the seven claims the Plan now contends are medical necessity denials fail to include one or more of the elements identified in


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corresponding EOBs did not contain the name and phone number of the reviewer because the denials were contractual or administrative conditions, and not because of medical necessity19.

The Plan communicates with both providers and members using the EOBs. Additional information regarding clinical criteria and guidelines used for basis of the Plan’s determination are included within appeals letters and are made available upon request. If a provider or member requires further explanation of the criteria, guidelines, or clinical reasons used for a decision based on medical necessity, the Plan provides this information to the member by way of correspondence, including the required language specified by the Department.


Based upon the corrective actions undertaken, the Department has determined that this deficiency has not been fully corrected. While the Plan has implemented monthly audits of its EOBs to ensure consistency, as well as revised its denial codes to be more clear and concise, it has not fully corrected this deficiency. The Department will assess the Plan’s compliance with the Act, by conducting file and policy review during the follow-up survey.

Deficiency #12: The Plan does not effectively review the dental care services

rendered to its enrollees to identify problems, including over- and under-utilization of services, and take effective action to improve care. The Plan does not review its clinical criteria on an annual basis to ensure that such criteria or guidelines are consistent with sound clinical principles.

Statutory/Regulatory Reference(s): Sections 1363.5(b)(1) through (3); Rule 1300.70(a)(1); Rule 1300.70(b)(2)(G)(5)

Assessment: The Department found that the Plan does not effectively gather and review data regarding services rendered to enrollees. Per the Plan’s utilization management policy, the Dental Director reviews the results of utilization trending reports and analyzes the data. The trending reports are submitted to the Quality Improvement Committee for determination of corrective action. This committee subsequently creates a monthly report, which is used to track and trend over- and under-utilization. From this report, the Dental Director is required to identify providers who are two standard deviations above or below the norm for (a) cost of services per encounter and (b) the number of services per encounter.

Section 1367.01(h)(4). Furthermore, the Department in its initial review determined that 42 claims denied were based in whole or part on medical necessity. (See Footnote 8, above.) Therefore, the Department denies the Plan’s request to remove this deficiency from the report. 19 The Department in its initial review determined that 42 claims denied were based in whole or part on medical necessity. (See Footnote 8, above.)


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When the Plan identifies providers as over- or under-utilizing services, it determines if they are “teachable” or if the providers need to be removed from the Plan’s network. The Quality Improvement Committee Meeting Minutes (fourth quarter 2010 through second quarter 2012) included graphs showing how many providers were identified as deviating from the mean, but the graphs (as well as the Plan) could not substantiate how many providers participated in the survey.

The Dental Director stated in interviews that the data gathering and reporting systems are flawed, resulting in inaccurate data analysis because only a very few number of providers actually submit encounter data. In the submitted pre-onsite materials, under Utilization Profiling Criteria and Standards, the Plan wrote under its processes that it accesses utilization data from two sources, one of which is utilization data by “Encounter history from Anthem Blue Cross [general practitioners.] The drawbacks are that we have no way to verify completeness or accuracy.”

Encounter data: The Provider Contract contains a provision specifically relating to encounter data as follows:

PARTICIPATING DENTAL OFFICE agrees: To provide ANTHEM with Member encounter data, on a weekly basis, in an acceptable format set forth in the Administrative Guidelines. Additionally, Network Bulletin #136, Subject: Encounter Data Reporting Process, Policy states: At the present time, Blue Cross of California expects providers as a condition of their contract to submit encounter data supporting services rendered to Blue Cross of California members. All services must be reported.

The Plan has not implemented effective corrective actions to enforce the above provision. In interviews, Plan staff stated that encounter data is not well collected and reported and they were unable to estimate the proportion of encounters that were missing.

During interviews, the Dental Director described the Plan’s procedure for addressing providers who were found to deviate from the norm. He stated that the Plan sends a letter to providers identified on the reports as deviating from the norm, indicating that they are in violation of the policy. However, the Dental Director stated that no follow-up actually occurs and stated that the Plan has not conducted any enrollee or provider satisfaction surveys to obtain input and perspective regarding the quality of care received.

Additionally, the Quality Improvement Committee Meeting Minutes indicate that the Plan had not conducted an annual review of its utilization management criteria in 2011 or 2012. The Plan uses these criteria to guide its determinations to authorize, deny, delay, or modify dental care services. The Plan’s outdated criteria do not reflect and represent current accepted professional standards of practice based on sound clinical principles.

Rule 1300.70(a)(1) requires that each plan’s “Q[quality] A[ssurance] Program … must document that the quality of care provided is being reviewed, that problems are being identified, that effective action is taken to improve care where deficiencies are identified, and that follow-up is planned where indicated.” Rule 1300.70(a)(3) requires


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that each Plan “monitor whether the provision and utilization of services meet professional recognized standard of practice.” More specifically, Rule 1300.70(c) requires the Plan “design and implement reasonable procedures for continuously reviewing the performance of health care personnel, and the utilization of services and facilities.” Given that the data and reports the Plan uses to review these utilization issues are incomplete and involve only a small number of providers, the resulting analysis is inadequate. Because the Plan failed to demonstrate that it effectively reviews the dental care services rendered to its enrollees to identify problems, including over- and under-utilization of services, and take effective action to improve care, the Department finds it in violation of Rule 1300.70(a)(1),(2) and Rule 1300.70(c).

Section 1363.5(b) requires that the criteria or guidelines used by each plan to determine whether to authorize, modify, or deny health care services shall be 1) developed with involvement from actively practicing health care providers, 2) be consistent with sound clinical principles and processes, and 3) be evaluated, and updated if necessary, or at least annually. The Plan’s criteria had not been reviewed and updated with input from providers at any point during the two-year review period. As a result, the Plan has not ensured that its criteria are consistent with the most current clinical principles and processes. Therefore, the Department finds the Plan in violation of Section 1363.5(b).


Plan’s Compliance Effort: The Plan stated in its response that it “monitors potential quality of care issues, over utilization, under-utilization, and appropriateness of care through a variety of processes. Those processes include post treatment review, Grievance Committee scrutiny of over and under-utilization grievances, California Association of Dental Plans certified dental consultant office audits evaluate utilization, and statistical analysis of procedure distribution and frequency.” The Plan explained that it had enhanced its PQI review procedures and corrective actions for instances of over and under-utilization. A dentist also retrospectively reviews claims for appropriateness of the treatment and takes corrective action as required. The Plan noted that the “California Association of Dental Plans audit tool utilized by certified dental consultants evaluates over and under-utilization during chart reviews.”

The Plan stated that it “performs UM analysis utilizing family of codes and standard deviation from mean. The Dental Director reviews results of utilization trending reports, analyzes data ... .” To promote submission of encounter data for such reports, the Plan added a new Access Survey question to remind providers of their contractual obligation to submit encounter data. The Plan described a new strategy to enhance utilization monitoring; it no longer markets DHMO programs that do not provide an incentive for providers to submit encounter data. “One supplement is paid per office visit ... . These supplemental payments are made from submitted encounter data. As a result, the plan anticipates an increased in the volume of encounter data received improving the validity of our utilization management reports.”


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To address the Department’s concerns surrounding criteria development and review, the Plan submitted its policy regarding utilization management review, most recently approved by the Quality Improvement Committee in June 27, 2014. The Plan reported that this policy “states that the clinical criteria is developed with involvement of actively practicing dentists, is consistent with clinical principles and processes, and is evaluated and updated at least annually.” The Plan also reported that during 2014 it implemented Clinical Process Aids that describe various criteria and guidelines to supplement existing criteria and guidelines listed in the documents “Guidelines for Approval of DHMO Specialty Referral Claims” and “DRU Review Guidelines. As part of its corrective action the Plan submitted guidelines, which it stated “summarizes these clinical principles listing Clinical Process Aids delineating clinical review criteria and guidelines.” The Plan also described the Dental Review Unit (DRU), consisting of dentists and dental assistants, which holds informal and formal meetings where clinical criteria are reviewed to ensure that such criteria or guidelines are consistent with sound clinical principles. The Plan, therefore, reviews the clinical criteria quarterly instead of annually.


The Department finds that the Plan has implemented strategies to improve the quality of the encounter data it uses for review of under and over utilization – most notably supplemental payments based upon encounter data. The Plan did not specify the dates it implemented these new strategies nor did it provide any data (e.g., encounter data volume tracking reports, utilization trending reports) to show whether these strategies have resulted in data integrity improvements. Therefore, the Department finds that the Plan did not present evidence that the data and reports it uses to review these utilization issues are now complete, involve statistically sound numbers, and are based on reliable data. Additionally, the Plan did not provide any detail on the process, criteria, or results of its “statistical analysis of procedure distribution and frequency.”

For those approaches which address under- and over-utilization for individual providers (e.g., enhanced PQI procedures, retrospective claims review), the Plan again presented no data to show that these approaches have been effective in identifying problem providers. It also did not provide detail to describe the extent/volume/foci of its retrospective claims reviews.

With regard to development and review of criteria, the Plan’s policy pertaining to criteria utilization management review, is a mere declaration that clinical criteria will be developed with involvement from actively practicing dentists, be consistent with sound clinical principles and be evaluated/updated at least annually. It does not describe the Plan’s process for developing and reviewing the criteria. It does not, for example answer questions such as:

• Is there is a committee on a national or local level. If so, what committee? • What is the process for developing the criteria, who is involved and what are their

credentials? • What dental authority references are used? Are literature searches performed? • What is the process for review, evaluation, and approval of drafted criteria? • What committees will approve the criteria?


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This policy, therefore, does not demonstrate that criteria used by Plan are based on sound clinical principles.

The Department found that the Plan’s clinical review process aid presents the guidelines (and the literature references) for specialty referrals but also does not shed light as to how the criteria are developed, reviewed, and approved. This again does not demonstrate that criteria are based on sound clinical principles.

Finally, the role of the Dental Review Unit not fully described. While the group reviews criteria, it is unclear whether the four DDS members (out of 15 members) are responsible for writing or developing the criteria and who is ultimately responsible for approving the criteria.

Based upon the corrective actions undertaken, the Department has determined that this deficiency has not been fully corrected.

LANGUAGE ASSISTANCE

Deficiency #13: The Plan failed to demonstrate that: • it has updated its assessment of enrollee language needs

and enrollee demographic profile at least once every three years following the initial assessment in 2007;

• it collects, summarizes, and documents enrollee demographic profile data in a manner that enables the Plan to maintain confidentiality of personal information and to disclose the information to the Department on request for regulatory purposes and to contracting providers on request for lawful purposes, including language assistance purposes and health care quality improvement purposes.

Statutory/Regulatory Reference(s): Rule 1300.67.04(c); Rule 1300.67.04(e)(1)

Assessment: Anthem Blue Cross’ filing of its Language Assistance Program with the Department in 2008 encompassed all of its commercial business units including ABC Dental (the Plan). Plan staff stated in interviews that completing enrollee assessments and updating of enrollee profiles is the responsibility of Anthem Blue Cross’s corporate office. However, staff indicated that the Plan is responsible for maintaining its own policies and procedures for the Language Assistance Program as well as monitoring the Plan’s compliance with regulations, including monitoring all affected business units and contracted providers for compliance. The Plan receives individual enrollee data electronically from the Anthem Blue Cross’s corporate office on a regular basis, but staff does not know whether the enrollee profiles are updated and, if so, how and how frequently this is done.

Rule 1300.67.04(e)(1) requires health plans to “update its assessment of enrollee language needs and enrollee demographic profile at least once every three years following the initial assessment.” Plan policy and procedure LA-001-01 Enrollee Assessment states that in November 2007, Anthem Blue Cross (the corporate office) completed a demographic assessment of enrollee linguistic needs and used a


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geocoding process to identify census tracts for each member based on their reported residential address. The result of this assessment led to the Plan’s provision of interpretation and translation services in five threshold languages—Spanish, Chinese, Korean, Tagalog and Vietnamese.

The policy further states that a survey of language and cultural requirements is included in every membership packet that the Plan sends to every enrollee upon enrollment. As the corporate office receives completed survey questionnaires, it enters the data into a membership system for use by the Customer Care Advocates. However, Plan officers stated in interviews that they do not know the response rate for this survey nor do they know whether enrollees’ language needs are accurately/appropriately recorded/entered into the membership system by the corporate office and how often enrollee profiles are updated. Plan officers also do not know whether the corporate office has updated its assessment of enrollee language needs and enrollee demographic profile since the initial assessment in 2007. There was no documented evidence of reassessment submitted by the Plan.

Additionally, Rules 1300.67.04(c)(1)(A)-(C) requires that health plans collect, summarize and document enrollee demographic profile data in a manner that enables the Plan to maintain confidentiality of personal information and to disclose the information to the Department on request for regulatory purposes and to contracting providers on request for lawful purposes, including language assistance purposes and health care quality improvement purposes. The Plan’s policy and procedure (LA-001-01, Enrollee Assessment) does not address these requirements.

Because the Plan has not demonstrated that: (1) it has updated its assessment of enrollee language needs and enrollee demographic profile at least once every three years following the initial assessment in 2007; and (2) it surveys the linguistic needs of individual enrollees in a timely and appropriate manner; and (3) it collects, summarizes and documents enrollee demographic profile data in a manner that enables the Plan to maintain confidentiality of personal information and to disclose the information to the Department on request for regulatory purposes and to contracting providers on request for lawful purposes, including language assistance purposes and health care quality improvement purposes, the Department finds the Plan in violation of Rule 1300.67.04(c) and 1300.67.04(e)(1).


Plan’s Compliance Effort: Anthem Blue Cross Dental stated in their response to the Preliminary Report, that Anthem Medical has recently been in discussions with the Department regarding corrective action for Anthem’s Language Assistance Program and the assessment of enrollee languages. During the development of the corrective action plan, the Plan determined that, rather than perform a three-year census, the most cost effective way to satisfy the survey requirement was to leverage an annual Notice of Language Assistance (NOLA) to all California medical and dental members. The Plan indicated that a more robust version of the Notice of Language Assistance was included within the corrective action plan, submitted by Anthem Medical to the Department on


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November 20, 2014. However, the Plan indicated there was no indication of acceptance by the Department of the proposed change. The Plan confirmed that as soon as the Department approved the pending changes to the Language Assistance Program, the Plan intends to implement the proposed modifications.


Based upon the Plan’s response, the Department has determined that the Plan has not fully corrected this deficiency.

In order to develop and enrollee assessment in compliance with Rule 1300.67.04(c)(1), the Plan must survey its enrollees or use a disclosure and develop a demographic profile of its enrollee population to calculate threshold language using statistically valid methods for population analysis. Plans may use a variety of demographic data in developing a demographic profile, including census data, client utilization data from third parties, data from community agencies and third party enrollment processes including census data. Rule 1300.67.04(e)(1) requires the Plan to update its assessment of enrollee language needs and enrollee demographic profile at least once every three years.

The Plan failed to provide evidence that its updated its demographic profile and that its disclosure meets all requirements under Rule 1300.67.04(c)(1)(B). Rather, the notice requires providers to contact the Plan to request each enrollee’s preferred written and spoken language but does not address how the Plan or the enrollee will inform the provider of the preferred spoken or written language20. It appears, therefore, that the enrollee, who may be unable to communicate with the provider due to language barriers, may be required to ask the provider to contact the Plan to obtain their preferred spoken language.

It appears that the Plan intended to use the same corrective action plan deemed uncorrected in the Final Report for the Routine Medical Survey of Anthem Blue Cross of California, issued on March 24, 2015. Similarly, the Plan failed to demonstrate that it collects, summarizes, and documents enrollee demographic profile data in an manner that enables the Plan to maintain confidentiality of personal information and to disclose the information to the Department on request for regulatory purposes and to contracting

20 Notably, the Department found the Anthem Blue Cross of California’s Notice of Language Assistance (NOLA) was not sufficient to meet the statutory requirements of Rule 1300.67.04(c)(1)(B). As a result of the insufficient NOLA and failure to update its demographic profile, the Final Report, issued on March 24, 2015, on Page 47-48 found Deficiency #7, remained uncorrected and states:

The Plan provided an updated notice of language assistance that it sends annually to all enrollees in order to collect the enrollee’s preferred spoken and written language. However, the disclosure fails to inform how relevant providers will be notified of the preferred spoken and written language of the enrollee as required by Rule 1300.67.04(c)(1)(B). Rather, the notice requires providers to contact the Plan to request each enrollee’s preferred written and spoken language but does not address how the Plan or the enrollee will inform the provider of the preferred spoken or written language. It appears, therefore, that the enrollee, who may be unable to communicate with the provider due to language barriers, may be required to ask the provider to contact the Plan to obtain their preferred spoken language.


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providers on request for lawful purposes, including language assistance purposes and health care quality improvement purposes as required by Rule 1300.67.04(c)(1)(C).

Based upon the Plan’s response, the Department has determined that the Plan has not corrected this deficiency. The Department will assess the Plan’s compliance at the Follow-Up Survey. The Failure to bring the Plan’s operations into full compliance will result in this matter being referred to the Department’s Office of Enforcement for potential disciplinary actions pursuant to Section 1380(i)(1).

Deficiency #14: The Plan failed to demonstrate that it consistently provides

training for its staff regarding its Language Assistance Program

Statutory/Regulatory Reference(s): Rule 1300.67.04(c)(3)(A) through (D); Rule 1300.67.04(c)(4)

Assessment: The Plan cannot demonstrate that all key staff has undergone Language Assistance Program training.21

A review of the 2008 training announcement, Announcing CA SB853 Required Training for All Members Facing CA Associates, revealed that all identified associates were required to complete the curriculum by December 19, 2008, i.e., prior to the effective date of the Language Assistance Program in January, 2009. Per the announcement, the Managers of the Member Facing Associates were responsible for determining which associates would be required to complete the training. During interviews, Plan staff indicated that all employees (not just Member Facing Associates) are required to complete Language Assistance Program training.

Although policies requiring training are in place and training materials exist, the Plan does not ensure that training consistently occurs. Plan staff was not certain that all employees have completed the training and the Plan did not provide the Department

21 The Plan has established staff training for the Language Assistance Program for all employees identified as “Member Facing Associates,” defined as staff members in contact with members directly or indirectly. The Plan’s training unit of the Human Resources Department requires these staff members to register for and complete the California Culture and Diversity SB853 Curriculum training. Training is conducted in LearnPoint, the Plan’s web-based training portal provided by Anthem Blue Cross (the corporate office) where training curricula for various topics resides. The Language Assistance Program training curriculum consists of two courses: (1) SB853 Overview Course and (2) Culture and Diversity SB853, which together include instruction on the Plan’s policies and procedures for language assistance; working effectively with Limited English Proficient enrollees; working effectively with interpreters in person and through video, telephone and other media, as may be applicable; and understanding the cultural diversity of the Plan’s enrollee population and sensitivity to cultural differences relevant to delivery of health care interpretation services. The training SB853 Program document, Standard for Staff Training, describes the provision of training at three levels: Level 1- All associates and vendors with any contact with members, directly or indirectly. Level 2- Department specific associates with specific processes and procedures that will change because of SB853. Level 3- Role specific interpretive services management. A limited group of associates will be trained on how to work with the third-party interpreter vendor, three-way conference calls, etc.


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evidence to prove training was completed. The Compliance Manager and the Clinical Quality/Compliance Administrator told the Department that they had taken the training but could not remember when that occurred. They were unable to produce a list of those employees who have taken the training, indicating that it was the responsibility of the corporate office to track this. The Department’s interviews with staff suggested that the proportion of those not taking training might be significant. For example, the Dental Director, who is responsible for the oversight of the Language Assistance Program, stated he had not received any training regarding the Language Assistance Program; additionally, two staff members present at the Grievance Department interview could not recall taking training.

During the onsite visit, the Customer Service Manager, who is located in Colorado Springs, submitted to the Department a copy of the six-week course outline for newly hired Customer Care Advocates to aid them in answering inquiries from callers. The 18-page course outline showed one topic (in the sixth week) related to Language Assistance. The topic consisted of instruction on how to call the Cyracom Language Line. (Cyracom is the Plan’s interpretation service vendor.) The Customer Service Manager tracks staff members who have completed the course and follows up with those who have yet to complete the course as evidenced in the Class Summary, a report that identifies advocates who have and have not completed the training. There is no evidence that Customer Care Advocates receive additional training (e.g., California Culture and Diversity SB853 Curriculum training in LearnPoint) regarding the Language Assistance Program. When queried, the Customer Service Manager did not know whether each Advocate has completed the CA SB853 LearnPoint-based training. She recalls having taken the CA SB853 training herself, through LearnPoint, but does not remember when that occurred.

In interviews, the Compliance Manager and the Clinical Quality Compliance Administrator stated that staff training is the corporate office’s responsibility. There is no one Plan officer who is responsible for ensuring that all staff, in all three levels mentioned above, is trained adequately and in a timely fashion. No one in the Plan knows if all employees who are required to complete the training have actually done so.

Rule 1300.67.04(c)(3) states:

Every Plan shall implement a system to provide adequate training regarding the plan’s language assistance program to all Plan staff that has routine contact with limited English proficient (LEP) enrollees. The training shall include instruction on:

Knowledge of the Plan’s policies and procedures for language assistance; Working effectively with LEP enrollees; Working effectively with interpreters in person and through video, telephone and other media, as may be applicable; and Understanding the cultural diversity of the Plan’s enrollee population and sensitivity to cultural differences relevant to delivery of health care interpretation services.


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Additionally, Rule 1300.67.04(c)(4) requires each plan to monitor its Language Assistance Program and make modifications as necessary to ensure compliance.

Because the Plan failed to demonstrate that it consistently provides training for its staff on the Language Assistance Program, the Department finds the Plan in violation of Rules 1300.67.04(c)(3)(A) through (D). Because the Plan has not monitored its training program to ensure that staff have received training, the Department also finds the Plan in violation of Rule 1300.67.04(c)(4).


Plan’s Compliance Effort: As part of its corrective action plan, the Plan affirmed that new associates and existing associates who have contact with members are required to take a California Language Assistance Program and Culture and Diversity Overview training on an annual basis, in August. The online training class provides a broad overview of SB853, the Health Care Language Assistance Act, inclusive of the provision of language services including requiring health plans and health insurers to provide their enrollees with interpreter services, translated materials, and to collect data on race, ethnicity, and language to address health inequities.

The Plan stated that it records completion of all staff training in electronic format. The Director of Customer Care and Managers of the Utilization Management and Grievance and Appeals Departments are responsible for oversight to ensure that adequate training is delivered and that completion of training is documented. The Plan submitted to the Department a list of Dental Customer Service Associates who completed the online Language Assistance Program training, as well as Grievance and Appeals staff who recently to the on-line training program.


Based upon the corrective actions undertaken, the Department has determined that this deficiency has not been fully corrected. The Plan’s compliance effort did not provide evidence of a revised staff education policy and procedure, approved by the Quality Improvement Committee, that all associates are required to take language assistance training on an annual basis, nor did the Plan provide policies, which stipulate the delegation of authority for oversight of staff training. While the Plan provided confirmation of recent language assistance training for members of the Grievance and Appeals Department, the Plan did not provide evidence that it performed training of its operational staff on annual basis as stipulated in the Plan’s response. Finally, the Plan did not provide evidence that all of its staff, for example, the Dental Director who is responsible for the oversight of the Language Assistance Program, have received training.


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Deficiency #15: The Plan does not monitor its Language Assistance Program and make modifications as necessary to ensure compliance.

Statutory/Regulatory Reference(s): Rule 1300.67.04(c); Rule 1300.67.04(c)(4)(A)

Assessment: The Plan had no policies and procedures regarding compliance monitoring of its Language Assistance Program at the time of the onsite survey. Plan staff confirmed in interviews that there are no current monitoring mechanisms in place to measure the Plan’s compliance with its Language Assistance Program standards. Plan staff stated that analysis of grievances and appeals will be, in the future, a major component of its monitoring program, but such activity has not commenced. There is currently no grievance category for language issues that would allow the Plan to identify, sort and analyze language assistance-related complaints for quality improvement purposes.

The Plan submitted a draft copy of a policy and procedure, LA-001-07, entitled “Compliance,” but this policy has not been reviewed and approved by the Quality Improvement Committee. According to the Customer Service Manager, the Plan had not implemented any of the activities described in the policy. Policy and procedure LA-001-07 states:

The Dental Director is responsible for monitoring compliance with the Language Assistance Program. On a quarterly basis, he or she reviews a report that shows how many members have accessed our language line through the Customer Care Advocates, Claims Associates or Grievance Analysts. The report information is housed in the Call Care Browser system, and is reported to the Quality Improvement Committee.

The policy further states:

On a quarterly basis, a survey will be sent to our operations teams to gather data on requests for written translations. The results of these surveys will be incorporated into our report to the Committee.

This proposed monitoring policy is limited. The monitoring activities do not include all business units affected by the Language Assistance Program, nor all aspects of the Program, (e.g., customer service complaints, requests for and issues regarding translation and interpretation services, provider compliance, and vendor compliance.) In addition, the policy does not describe how the Plan will collect data from various affected business units to measure compliance.

Rule 1300.67.04(c) requires that the “language assistance program … be documented in written policies and procedures, and address standards for compliance monitoring”. Rule 1300.67.04(c) (4)(A) further requires that “[e]very plan shall monitor its language assistance program … and make modifications as necessary to ensure compliance with Section 1367.04 of the Act and this section”. Because the Plan’s Language Assistance Program policies and procedures do not address compliance monitoring, the Department finds the Plan in violation of Rule 1300.67.04(c). Because the Plan has not


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conducted monitoring of the program, the Department finds the Plan non-compliant with the requirements of Rule 1300.67.04(c)(4)(A).


Plan’s Compliance Effort: As part of its corrective action, the Plan stated that compliance monitoring will be implemented as soon as the revisions to Anthem’s Language Assistance Program is finalized upon further discussions with the Department, including reporting and assessment of language needs. The Plan reiterated that it would implement the compliance monitoring described in the corrective action plan submitted by the medical plan, Blue Cross of California, to the Department on November 20, 2014, upon Department approval.

The plan currently tracks and receives monthly reports on demographic profiles indicated within the Plan’s membership systems. Plan personnel responsible for oversight of the Language Assistance Program implementation and compliance include the Dental Director, and dental compliance staff who maintain communications with the Blue Cross of California (Anthem Blue Cross) medical plan and corporate offices regarding program implementation, changes, and/or improvements.

The Plan stated that its grievance production log, managed by a dedicated grievance and appeal analyst, now includes a category called “language assistance” which will allow the Plan to identify, sort and analyze language assistance-related trends for quality improvement purposes. Finally, the Dental Director reviews all grievances, including those related to the Language Assistance Program.


Based on the Department’s review of the Plan’s response to the deficiency, it appears the Plan intended to use the corrective action plan submitted in the Anthem Blue Cross of California Routine Medical Survey, submitted November 20, 2014, as its response22.

The Department found no evidence of compliance monitoring policies or procedures submitted by Anthem Medical as part of a corrective action. Additionally, the Plan did not provide finalized compliance policies and procedures with evidence of approval by the Plan’s Quality Improvement Committee. The Plan’s corrective action did not provide evidence of effective compliance oversight including monthly reports, revised grievance procedures detailing Plan revisions and inclusion of a “language assistance” category. Finally, the Plan did not provider evidence that all grievances including those identified as language assistance complaints are reviewed by the Dental Director.

22 Notably, the Department found in the Final Report, issued on March 24, 2015, that the language assistance deficiency in the Anthem Blue Cross of California Medical Survey was not corrected because the NOLA was not sufficient to meet the statutory requirements of Rule 1300.67.04(c)(1)(B) and because the it failed to update its demographic profile once every three years as required by Rule 1300.67.04(e)(1),


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Based upon the Plan’s response, the Department has determined that the Plan has not corrected this deficiency. The Department will assess the Plan’s compliance at the Follow-Up Survey. The Failure to bring the Plan’s operations into full compliance will result in this matter being referred to the Department’s Office of Enforcement for potential disciplinary actions pursuant to Section 1380(i)(1).

Deficiency #16: The Plan’s contract with providers does not specifically require

compliance with the Plan’s Language Assistance Program standards.

Statutory/Regulatory Reference(s): Section 1367.04(f) Rule 1300.67.04(e)(4)

Assessment: The Plan’s service agreement with providers, any subsequent contract addendum/modification, nor the notification/bulletin (Bulletin#141) sent to providers in 2010 regarding the Plan’s Language Assistance Program contain provisions for provider compliance specific to Language Assistance laws and regulations. Page 4 of 16 of the Standard Professional Services Agreement with Dental Providers broadly states:

4.03 (Participating dental office agrees) to comply with and ensure that each participating dentist and its other employees comply with and continues to comply with all applicable state and federal laws and regulations and continually meet all legal, professionally and community standards of care

There is no specific mention in the service agreement of compliance with the Plan’s Language Assistance Program or cooperation with the Plan by providing information necessary to assess compliance with the program.

The only communication sent to contracted providers regarding the Plan’s Language Assistance Program is Bulletin #141, which Plan officers indicated should serve as an insert to the Provider Manual. Bulletin #141 simply states:

Provider Responsibilities:

Notification: Providers must notify members of the availability of health plan interpreter services and strongly discourage the use of minors, friends and family who may act as interpreters.

Plan has multilingual signage available for providers to post in areas likely to be seen by members; this signage notifies members of the availability of interpreter services that are provided by the Plan.

Documentation of notification: If the member chooses to use a friend, family member or minor as an interpreter after being notified of the availability of free interpreter services, the provider must document this choice in a prominent place in the member’s dental records. (We suggest following the protocol your office uses for HIPAA and/or Dental Materials Fact Sheet documentation.)


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While Bulletin #141 notified the providers of their responsibilities to notify enrollees of the availability of free interpreter services and multilingual signage for providers, it did not mention any other standards of the Language Assistance Program and/or the requirements for compliance, including their specific responsibilities to provide information to the Plan so that it may assess compliance. There is no evidence in Bulletin #141 that Plan providers were made aware of the Plan’s Language Assistance standards.

The Department visited the Plan’s website and confirmed that there is a section on its website about its Language Assistance Program, but the Plan has no process to monitor whether contracted providers have taken the time to visit the website for the purpose of informing themselves about the Plan’s Language Assistance Program. The Department also noted that the Plan included on its website the educational information contained in a publication produced by the Industry Collaboration Effort (ICE) titled, Better Communication, Better Care: Provider Tools to Care for Diverse Populations, a tool kit for physicians and other health care professionals designed as a resource to better communicate with a diverse patient population. However, there is no evidence that the providers were made aware of the availability of this information on the Plan’s website. Plan documents reviewed by the Department, including Bulletin #141, do not mention this information. The website also does not communicate provider compliance requirements with the Program and nor does it inform providers of the requirement to cooperate with the Plan by providing information necessary to assess compliance.

Section 1367.04(f) states that contracts between a plan and a provider must require providers to comply with Language Assistance Program standards and cooperate with the Plan by providing any information necessary to assess compliance. Similarly, Rule 1300.67.04(e)(4) states that every contract between a health care provider and a plan, including a specialized plan, that is issued, amended, delivered or renewed on or after January 1, 2009, shall require compliance with the Plan’s Language Assistance Program standards. Because Plan contracts fail to require providers to comply with Language Assistance Program standards and to cooperate with information requests for assessing compliance, the Department finds the Plan in violation of Section 1367.04(f). The Department also finds the Plan in violation of Rule 1300.67.04(e)(4) based upon its failure to require providers to comply with Language Assistance Program standards.


Plan’s Compliance Effort: The Plan affirmed that it would revise its Provider Agreements to include the requirement for compliance with the Plan’s Language Assistance Program standards and file that revision with the Department Division of Licensing, as an amendment to the Plan’s provider contracts. The Plan stated that upon closure of this filing, the Plan would ensure that all newly executed provider contracts include a provision requiring compliance with the Plan’s Language Assistance Program standards. Additionally, that Plan confirmed an article in the next scheduled dentist newsletter would inform all participating providers of the revisions to the provider contract to requiring compliance with the program. Finally, the Plan stated that the


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Language Assistance Program provision would be included into all existing contracts no later than the next contract revision.


Based upon the corrective actions undertaken, the Department has determined that the Plan has not corrected this deficiency. The Plan has not submitted evidence of implementation of its corrective action plan, including:

• Revised Provider Agreements showing evidence of provider compliance with the Language Assistance Program standards,

• Evidence showing the Plan’s providers received copies of the revised amendment to Provider Agreement.

• Copy of the scheduled Plan dentist newsletter informing participating providers of the revisions to the provider contract requiring compliance with the Language Assistance Program.


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SECTION II: SURVEY CONCLUSION

The Department has completed its Routine Survey. The Department will conduct a Follow-Up Review of the Plan and issue a Report within 14-16 months of the date of this Final Report. The failure to correct all deficiencies at issuance of the Follow-Up Survey Report may result in a referral to the Department’s Office of Enforcement for disciplinary action pursuant to Section 1380(i)(1).

In the event the Plan would like to append a brief statement to the Final Report as set forth in Section 1380(h)(5), please submit the response via the Department’s Web portal, eFiling application. Click on the Department’s Web Portal, DMHC Web Portal

Once logged in, follow the steps shown below to submit the Plan’s response to the Final Report: Click the “eFiling” link. Click the “Online Forms” link Under Existing Online Forms, click the “Details” link for the DPS Routine Survey

Document Request titled, 2012 Routine Dental Survey - Document Request. Submit the response to the Final Report via the “DMHC Communication” tab.

https://wpso.dmhc.ca.gov/secure/login