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Molina Healthcare of California Slapped with $1M Fine for Delayed Payments

Analysis  |  By John Commins  
   June 28, 2022

Molina has also paid $80 million in disputed and delayed claims to providers, plus $1.8 million in interest.

Molina Healthcare of California has paid a $1 million fine levied by state regulators for failing to timely acknowledge and resolve nearly 30,000 provider disputes between September 2017 and September 2018.

In addition to corrective actions ordered by the California Department of Managed Health Care, Molina has also paid $80 million in disputed and delayed claims to providers, plus $1.8 million in interest. 

"It is important health plans promptly and accurately pay claims to hospitals, doctors and other providers when health care services are provided to enrollees to ensure the financial stability of providers, and the overall stability of the healthcare delivery system," DMHC Director Mary Watanabe said.

"Molina's systemic failures to timely resolve provider disputes caused payment delays, potentially jeopardizing the financial stability of providers. The plan has agreed to take corrective actions including remediating payments to impacted providers plus interest."

Molina did not return email requests for comment from HealthLeaders.

California health plans are required to have a Provider Dispute Resolution program for claims dispute with providers. State law requires plans to identify and acknowledge each provider dispute within two working days of the date of receipt of an electronic provider dispute, with 15 business days to respond.

Plans must also resolve each provider dispute or amended provider dispute and issue a written determination stating the pertinent facts and explaining the reasons for the plan's determination within 45 working days after the date of receipt.

As part of the required corrective actions, and in addition to remediating payments to providers, Molina must demonstrate compliance with acknowledgment and resolution timeliness requirements. 

If a provider disputes Molina's PDR process, or the plan takes longer than 45 days to issue a written determination, the provider can contact the DMHC Help Center's Provider Complaint Unit for further assistance. 

“It is important health plans promptly and accurately pay claims to hospitals, doctors and other providers when health care services are provided to enrollees to ensure the financial stability of providers, and the overall stability of the health care delivery system.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


KEY TAKEAWAYS

California health plans are required to have a Provider Dispute Resolution program for claims dispute with providers.

State law requires plans to identify and acknowledge each provider dispute within two working days of the date of receipt of an electronic provider dispute, with 15 business days to respond.

Plans must also resolve each provider dispute or amended provider dispute and issue a written determination stating the pertinent facts and explaining the reasons for the plan’s determination within 45 working days after the date of receipt.

As part of the required corrective actions, and in addition to remediating payments to providers, Molina must demonstrate compliance with acknowledgment and resolution timeliness requirements.


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