Project Experience

MHU’s major clients include regulatory agencies such as the DMHC and the California Department of Justice (DOJ). Both agencies have regulatory authority over California licensed health plans.  The following is a brief summary of selected activities under contract assisting the DMHC and DOJ:

 

Develop survey protocols

Examples are:

  • Technical Assistance Guides for Routine Medical Surveys of Full Service Plans,  Dental Plans, Vision Plans, Behavioral Health Plans and Employee Assistance Programs;
  • Technical Assistance Guide for Assessment of Health Plan Management of Claims;
  • Technical Assistance Guide for the Review of Evidence of Coverage and Disclosure Forms;
  • Technical Assistance Guide for the Review of Provider Contracts; and
  • Technical Assistance Guide for Non-routine Surveys to Detect Post Claims Underwriting.

 

Conduct medical surveys:

  • Performed well over 200 routine and non-routine medical surveys of full-service and specialty licensed health plans including full service, dental, behavioral, vision and employee assistance programs; as well as reviews of Medi-Cal managed care plans that under Section 1115 Waiver enroll Seniors and Persons with Disabilities (SPDs.  Areas of review include the assessment of medical/utilization management, quality assurance, consumer grievances, access and availability of health care services, claims payment practices, provider dispute resolutions, health care coverage rescission and cancellation practices, language assistance programs, etc.
  • Conducted in-depth analysis of findings to determine regulatory compliance and prepared detailed deficiency-based reports.
  • Provided recommendations for improvements.

 

Survey Protocol Development

Under contract with the Department of Managed Health Care of California (DMHC), MHU authored the protocol "Technical Assistance Guide for Routine Medical Surveys of Full Service Plans" and the surveyor's tool, "Survey Findings". The protocol is used by the DMHC to measure health plans' performance against relevant Knox-Keene requirements.

Since 2001, MHU has developed several other protocols used by DMHC in routine and non-routine surveys including the Technical Assistance Guide for Routine Medical Surveys of Dental Plans.


Routine Medical Surveys of California Health Plans

MHU has conducted hundreds of regulatory surveys of full-service and specialty plans throughout California including dental and behavioral health plans. Due to the combined efforts of DMHC, MHU and the health plans, the average number of deficiencies found per plan has decreased significantly over the 6 years since DMHC was established.

 

Investigation of Health Plans' Rescission Practices

MHU was charged with investigating allegations of post-claims underwriting by CA health plans. MHU worked with DMHC legal staff to develop research questions and review tools, then conducted onsite visits of five of the largest health plans to review each plan's pre-enrollment underwriting and post-enrollment rescission practices and case files. As a result of this project, plans have modified internal policies and review processes, California has drafted Proposed Adoption of Knox-Keene Sections 1300.89.1, and 1300.89.3 and million-dollar penalties have been levied.

 

Claims Surveys and Investigations

MHU was contracted to examine the emergency claims payment policies of a major California managed care company, resulting in discovery of numerous deficiencies in claims payments. As a consequence, a judgment of several million dollars was brought against the plan for claims denials.

MHU was also lead investigator at several other health plan reviews, where we uncovered deficiencies in claims practices that resulted in the implementation of new processes and best practices.

 

Mental Health Parity in California

MHU conducted plan surveys to evaluate compliance with the Parity Act, prepared individual plan reports, and prepared an extensive issue-oriented analysis of parity implementation in California.


Focused Survey of Member-Initiated Quality of Care Complaints

MHU provided a research design expert and a physician to assist DMHC's team of legal and medical personnel in this non-routine survey of a plan's processes for addressing complaints. The survey resulted in the plan being required to submit a corrective action plan to address deficiencies.


Technical Assistance Guide/Review Protocol for Review of Evidences of Coverage (EOCs)

MHU assisted DMHC's Division of Licensing in the development of the Technical Assistance Guide for the review of the Evidence of Coverage and Disclosure Form.

 

Technical Assistance Guide for Language Assistance

To guide health plans in the implementation of new requirements for assessing the linguistic needs of enrollees and providing translation/interpretation services and to assist the state in monitoring plan compliance. MHU developed a Technical Assistance Guide which defines compliance requirements and details the criteria and processes that will be used to assess plan compliance.

 

Community Health Needs Assessment and Strategic Planning

MHU provided the Northwest Pennsylvania AIDS Planning Coalition with assistance in developing a regional health services plan to meet the short and long term needs of the community and its residents affected by HIV. MHU developed a study methodology, designed data collection tools for surveys and interviews, collected the data, conducted data analysis and prepared a report containing findings and recommendations. MHU has also conducted strategic planning sessions with the Coalition leadership and is currently performing a needs assessment to evaluate the role of faith-based organizations in providing services to victims of HIV/AIDS.

 

Focused Investigations of Critical Health Care Issues

MHU was contracted by the Department of Justice to conduct a focused investigation of inappropriate claims payment by a major health plan resulting in process improvement and fairer payment practices positively impacting network and non-network providers.

MHU was called upon to conduct a focused investigation of a major health plan’s Kidney Transplant Program following a negative newspaper article alleging inappropriate handling of transplant candidates. The investigation resulted in the discontinuation of that health plan’s transplant program.


For a complete list of MHU's project history please contact MHU directly

 
 

Contact Us Today

Managed Healthcare Unlimited, Inc
133 The Promenade North Unit #323
Long Beach, CA, 90802

Phone: (562) 436-3451
Fax: (562)437-8334

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