If you are a client of Kaiser Permanente and feel that they are not providing you with the level of healthcare that you need, then you may need to seek out the help of an experienced legal firm. Stop Insurance Denial Law Firm has experience in precisely these types of cases and we are well aware of Kaiser’s unsavory practices that hurt patients and erode public trust in their services. We serve clients all over the United States and we can help you today.
What is Kaiser Permanente?
Kaiser Permanente, which has over 7 million members, is the largest “health maintenance organization” (also known as an HMO) in California. Kaiser plays an integral role in California’s healthcare infrastructure by operating over thirty-five (35) hospitals as well as several hundred clinics all over the state. Kaiser is also crucial in providing treatment for mental health to residents of California and is the second largest provider of mental health treatment (the largest being the state of California itself).
Kaiser provides its members with a comprehensive cross-section of outpatient, inpatient, and emergency medical services. These services are effectively provided by thousands of health care practitioners.
However, over the years Kaiser has come under fire for consistently failing to provide an adequate level of care for its members. It has also been the subject of multiple lawsuits and legislative investigations to determine its culpability in the failure to provide basic standards of medical treatment. Multiple analyses have determined that Kaiser’s medical services infrastructure is seriously understaffed and that it frequently fails to provide medical care in an appropriate and/or timely manner. HMO members will often suffer from excessive delays in getting their medical services; this effectively pushes most patients to seek out medical treatment elsewhere (paid for out of their own pockets).
Kaiser also frequently denies health insurance claims for legitimate medical conditions. It may do so for any number of spurious reasons and if you have failed in getting your claim approved by going through the standard channels, then you may need to retain a legal team who has experience in dealing with Kaiser’s denial of insurance claims. It is depressingly common for the HMO to put up roadblock after roadblock to a person’s necessary medical treatment.
National Union of Healthcare Workers (NUHW) Study
The National Union of Healthcare Workers (also known as the NUHW) released a comprehensive study of Kaiser Permanente’s medical services that came to overwhelmingly negative conclusions regarding the HMO’s standard of care. It was based on a survey of thousands of clinicians working with and for Kaiser, as well as extensive documentation from court filings, patients, and regulatory agencies. The study basically concluded that Kaiser often does not comply with health laws in California that were enacted to guarantee patients timely and prompt access to medical treatment.
The report also states that the failures of the company are systematic and widespread. These failures described in the report are serious enough to merit extensive investigations by federal and state authorities. There have also been various lawsuits filed by private and public customers. The report also found that in spite of receiving over ten (10) billion dollars per year from Medicare in order to provide various medical services, Kaiser was improperly coding evaluation procedures for patients, resulting in potentially fraudulent claims being made to Medicare.
Kaiser’s Failure to Provide “Timely Access” to Medical Services
This same report, in addition to various investigations undertaken by state authorities, found that Kaiser often violated California health laws that require HMOs to provide their customers with prompt and timely access to necessary medical services. These California health laws were specifically designed to protect patients from HMO’s who may drag their feet and hold up time-sensitive medical procedures that are necessary for their health and wellbeing.
These violations were largely reported by clinicians within Kaiser who acted as whistleblowers. They reported that patients were frequently made to wait at least four (4) weeks for follow-up appointments. This is in direct violation of a California law that mandates a waiting period of no more than ten (10) days for follow-up and initial visits. The only exception to this ten-day period is if a clinician has determined that it will not result in any negative repercussions for the patient’s health.
Furthermore, many of these same clinicians reported that the patients’ first appointments were frequently just orientation sessions during which initial evaluations were not undertaken. When the medical evaluations finally did take place, the clinicians reported that they were generally cursory, limited, and insufficient, even though Kaiser required them to code the evaluations to claim they were comprehensive and thorough. It is important to note that these clinicians were subject to employment contracts and productivity expectations that effectively required them to perform the evaluations as delineated by the HMO.
A particularly distressing statistic is that in a survey conducted of three-hundred and five (305) Kaiser physicians, almost ninety (90) percent of them claimed that they could not provide timely access to medical services due to chronic and widespread understaffing at their clinics. Over seventy-five (75%) percent of these surveyed clinicians claimed that return visits were very frequently scheduled too far into the future.
Furthermore, in 2005 the regulatory agency known as the California Department of Managed Health Care (also referred to as the DMHC) cited Kaiser for failing to provide its clients and patients with timely access to mental health care. In 2010, Kaiser was also fined seventy-five thousand ($75,000) dollars for delaying the autism spectrum disorder diagnosis of a child for almost eleven (11) months. Following an investigation, the DMHC determined that this failure to provide a timely diagnosis was a breach of contract with the patient and client and that it was inherently unreasonable to delay a vital diagnosis for so long.
Consistently denying a patient’s insurance claims could also be considered a failure to provide timely access to medical services. This is particularly true if there has been a pattern of behavior established in which the company frequently fails to perform its basic duties as a healthcare provider.
Falsifying Records and Inadequate Assessment Procedures
Investigations have also indicated that Kaiser has allegedly falsified scheduling records for patients. This unscrupulous practice was undertaken in an effort to avoid citations from state regulators for medical service and lengthy appointment delays. Whistleblower clinicians have reported that Kaiser frequently uses scheduling records that are known as “shadows”. These are deliberately misclassified appointments as well as falsified appointment cancellations in order to avoid being caught for failing to provide “timely access” to medical services.
These same whistleblower clinicians have also indicated that not only does Kaiser falsify scheduling records, but that the company has frequently required clinicians to perform patient evaluations as well as other services that fall far short of accepted clinical standards. Furthermore, Kaiser also codes these visits incorrectly, making this a direct violation of the HMO’s various private and public sector contracts. There have been extensive allegations, particularly in the city of San Diego, that Kaiser has allegedly required its treatment providers to spend half the recommended amount of time for assessing, diagnosing, and examining patients. Essentially, there is a widespread and systematic speeding-up of clinical assessment procedures that could result in serious repercussions, most notably misdiagnosis of the patient’s condition and inadequate medical care.
Further investigation of these allegations has resulted in whistleblower clinicians claiming that these unsavory practices are repeated in clinics all over the state of California. It is important to note that these clinicians are protected under California labor laws from being retaliated against. If you believe that you are the victim of one of these unscrupulous practices, then you may need to seek out the professional counsel of a law firm that specializes in healthcare denial. They may be able to present a compelling case that Kaiser, as your HMO, failed in its fundamental duty to provide you with adequate and timely access to medical services.
Investigations Into Kaiser’s Unsavory Practices
The California State Attorney General has launched an extensive investigation to determine if any of Kaiser’s systematic failures to serve the medical needs of its patients constitute “unfair business practices” under California Business and Professions Code, Section §17200 or “false advertising” under Section §17500. If the investigation deems that Kaiser did effectively violate one or both of these statutes, then the Attorney General may file a lawsuit on behalf of aggrieved customers or independently seek to impose punitive measures on the HMO.
Part of this same investigation involves the California Department of Justice (also known as the DOJ) and its Medi-Cal Fraud Unit. This division became involved when word of Kaiser’s falsified claims came to light via the whistleblower clinicians. If it is determined that these accusations have merit, then the contract between Kaiser and the Medi-Cal and Healthy Families program may be terminated. This would be a major punitive measure as Kaiser makes a great deal of its profit from providing services to the state of California.
Furthermore, the Office of the Inspector General of the United States Department of Health and Human Services has also initiated an investigation into Kaiser’s allegedly fraudulent acts with the Medicare program. The accusation is that Kaiser made false claims for mental health services under the Medicare Advantage program. If these accusations also have merit, then the HMO may find this working relationship terminated as well.
This has also spurred California congress, most notably the Assembly and Senate Health Committees, to review the findings of these various studies and investigations. Depending on their conclusions, they may enact additional safeguards to more stringently protect California consumers in the future.
These various investigations have triggered other repercussions and a crisis of confidence amongst Kaiser’s various customers. Other public and private entities who pay for health insurance from Kaiser are initiating comprehensive audits to determine if the company has defrauded or failed its customers. This is particularly true of large-scale public plans like the Federal Employee Health Benefits Program (known as the FEHB) and the California Public Employees’ Retirement System (known as CalPERS). Depending on what these audits find, these entities may become involved in litigation against the healthcare provider.
Class Action Lawsuit
Recently, a class action lawsuit against Kaiser (known formally as “Kaiser Foundation Health Plan”) was won by Wendy Gallimore and thousands of other patients. In this case, the company categorically refused to provide coverage for reconstructive surgery to remove excess skin following massive weight loss. Kaiser stated that they would only approve the claims if the patients suffered from functional problems. These various patients were repeatedly denied their insurance claims and found themselves with no choice but to file a lawsuit.
This resulted in a month-long trial in Alameda County and the Judge’s ruling that the HMO knowingly violated California’s reconstructive surgery law. This law is officially codified as Health and Safety Code, Section 1367.63 and it requires medical insurance providers to cover the cost of surgery if it will either improve the patient’s function or create what is legally known as “a normal appearance” as much as possible. Essentially, the judge ruled that the patients suffering from the excess skin were not allowed to seek covered treatment to achieve this “normal appearance” and that Kaiser’s constant denial of coverage constituted a breach of duty and health care obligations.
As a result of Gallimore v. Kaiser Foundation Health Plan, the HMO is now required to provide over one-hundred fifty ($150) million dollars in reconstructive surgery benefits to its members.
Kaiser’s Arbitration Process
In some cases, however, if you are unable to file a lawsuit, you may have to go through Kaiser’s arbitration process to file a complaint. Furthermore, any patients who are hoping to sue the HMO for medical malpractice must also go through this same arbitration process. In most cases, the results of the arbitration process will be upheld by the court. There may, however, be some narrow and specific exceptions to that rule.
Any customer who purchases coverage from Kaiser enters into a contract with the company by which they are subject to the arbitration contract. All patients have signed said contract, also known as a “binding arbitration”, as a condition of their membership to the HMO. Furthermore, these patients can receive their medical care from any number of clinics, hospitals, and/or medical groups. However, due to the binding arbitration, if a patient feels that they are being unfairly or unjustly denied coverage, then they can choose to go through the entire arbitration process.
Arbitration is a commonly used and widely accepted alternative to conventional court-based litigation. It is essentially a private moderation of some conflict, the results of which are almost always upheld by the public courts. Arbitration works by having the two parties present their case before a third party that is neutral (also known as “the arbitrator”). This arbitrator then rules on the case and determines if the plaintiff is entitled to any kind of compensation or damages.
Although arbitration happens outside the traditional court system, it is still absolutely necessary to have a strong attorney on your side that can help you make an effective and convincing case. Much like conventional personal injury lawsuits, arbitration involves both parties presenting evidence in order to make their respective cases. It is, for all intents and purposes, much like a trial and/or lawsuit.
The arbitration does not involve, however, a jury and/or a judge. During the arbitration, only the involved parties (the accuser and the accused), their legal representatives, and the neutral arbitrator are present. The process is slightly less formal than a lawsuit or trial. It is still necessary to have a skilled legal team as it involves the comprehensive presentation of relevant facts and the informed application of germane laws.
Any claims made about Kaiser are arbitrated by the Office of the Independent Administrator. An aggrieved patient must submit a petition for arbitration to the administrator. To find the exact address for the relevant administrator, check your medical records. The petition must provide a statement describing the patient’s grievance with the company, any damages the patient is seeking, the patient’s contact information, full name, contact information for their attorney, and relevant documentation that shows the patient has been unfairly denied coverage.
Kaiser will then provide a list of possible arbitrators and the proceedings must begin within sixty (60) days of appointing the said arbitrator. If both parties are unable to reach a settlement, then a “trial” will be held and the arbitrator will rule on the facts presented. The entire arbitration system is designed to resolve most cases within eighteen (18) months of the patient filing the grievance.
It is important to note, however, that courts are usually reluctant to overturn an arbitrator's decision. They usually will only do so if some sort of fraud was committed or if the arbitrator clearly had some conflict of interest and did not make an impartial ruling. Due to this fact, it is important that you speak to a legal professional to determine how you would like to begin your case against Kaiser. You can go directly to the courts to sue them for breach of contract and failure to provide adequate care, or you can choose to enter the internal arbitration process in hopes of receiving a settlement. It is best to have your attorney examine the details of your case and advise you on how best to proceed.
How Do I Find A Legal Team Near Me?
If you are sick and tired of having Kaiser bully you around and deny you coverage for necessary procedures, then you need to call Stop Insurance Denial Law Firm immediately. We can provide you with a free evaluation of your case to ensure that you have a good chance of getting the coverage you so desperately need and getting some compensation for your distress. Call our insurance denial attorney at 310-878-1771.