Allied Pacific Care IPA

Perhaps you are a member of Allied Pacific IPA and recently received a claim denial for a treatment or procedure your doctor ordered. This can be extremely frustrating – after all, your doctor knows you, knows your health history, and believes the treatment or procedure will help your specific medical issue. When you get your health insurance through an IPA, additional challenges may be involved in getting the medical care you need.

 An IPA is an Independent Physician Association, also known as an Independent Practice Association or an Independent Provider Association. When a network of doctors who have their own practices come together to provide healthcare, you have a medical group or an IPA. Most IPAs have a variety of practitioners, including General Practitioners as well as specialists. IPAs can also include urgent care clinics, imaging centers, and hospitals. 

IPAs contract with health insurance companies and managed care organizations like HMOs, PPOs, and POS plans. This allows the physicians in the IPA to remain independent while allowing members to be able to access the care they need. Nearly half of all California physicians were members of an IPA in 2022. Most physicians who are part of an IPA believe patient care is enhanced for members and that operational efficiency is increased. 

Physicians, hospitals, imaging centers, and urgent care clinics have additional negotiating power with health insurance companies, can provide more necessary services, and significantly reduce their overhead costs as part of an IPA. If you get your medical care through Allied Pacific IPA, you have options after receiving a claim denial. 

Your first step should be to speak to a highly skilled insurance denial attorney from the Law Offices of Scott Glovsky. Attorney Scott Glovsky wrote the training manual for law firms and lawyers – Fighting Health Insurance Denials: A Primer for Lawyers. If you are exhausted from dealing with a health issue and having to fight your insurance company to pay for the medical treatments you and your family need, Scott is ready to fight on your behalf. 

Overview of Insurance Provider Allied Pacific IPA of California

Allied Physicians of California IPA (DBA Allied Pacific IPA) was founded in 1992 and is headquartered in El Monte, CA. On the company website, Allied states it is committed to providing quality, patient-centered care while improving the standard of medical practices. 

Allied Pacific currently has one of the largest networks of medical professionals in the San Gabriel Valley, an extensive array of urgent care facilities, and multilingual customer service representatives. Allied Pacific IPA also has a Palliative Care Program, a Chronic Disease Management Program, a Post Acute Care Program, and a Wellness Center for seniors. 

Concourse Diagnostic Surgery Center, an ambulatory surgery center, was formed in March 2010. Also in 2010, APC acquired a minority interest in LaSalle Medical Associates. ApolloMed was formed in 2012. Network Medical Management (NMM) merged with ApolloMed and Allied Pacific in 2017 to form one of the nation’s largest value-based healthcare companies. In 2019, APC acquired Alpha Care Medical Group and Accountable Health Care IPA.  

Overview of Allied Pacific IPA of California Claim Denials

Allied Pacific is currently in active litigation (Ning Sun v. Allied Pacific IPA) for an alleged delay in the treatment of a member’s cancer. Other allegations point to treatment delays that could lead to irreversible health outcomes, such as missed  cancer treatment windows. The lawsuit was filed May 20, 2024, in the Superior Court of California, County of Los Angeles, Case Number 24PSCV01625. 

The lawsuit suggests that Allied Pacific IPA either ignored or rejected care coordination responsibilities. This resulted in the withholding of timely, potentially life-saving care.  The plaintiff alleges breach of contract and failure to act in good faith, which led to delays in accessing oncology services, missed windows of treatment, and avoidable emotional and physical suffering. Damages are alleged to be $114,888.50 in direct financial losses, plus non-economic damages and potential punitive damages. If the court finds negligence, bad faith denial of care, or contractual breaches, it could order a settlement or damages on behalf of the plaintiff.

What Are the Most Common Reasons Given by Allied Pacific IPA of California for an Insurance Claim Denial?

The most common reasons for insurance claim denials by Allied Pacific IPA and most insurers are related to coverage disputes. An insurer who does not want to pay for a more expensive treatment or procedure often “cloaks” the denial in words like “not medically necessary,” “investigational,” and “experimental.” Regardless of the fact that an IPA physician deems the procedure or treatment necessary, the insurance company could deny it. Sometimes, the IPA will deny a treatment or service, usually more expensive procedures like diagnostic tests or specialist referrals. 

Some procedures require pre-authorization, and when a patient is a member of an IPA, there can be confusion regarding whether the IPA or the insurance company is responsible for the approval. Regardless of who denies the care, the patient is left without the care he or she needs. If the IPA or the insurance company wrongfully denies a claim, this is known as a bad faith denial. Under California law, policyholders are allowed to assert their rights in the case of a bad faith denial. 

In some cases, the reason for denial is a simpler one. There may have been insufficient information in the claim, or there may have been an error on the claim, perhaps in coding or in the patient’s information. If this is the case, these errors can be fixed, and the claim resubmitted. Unfortunately, more often the reasons for denial are more complex. The contracts entered into between Allied Pacific IPA and health insurers essentially offer the IPA financial incentives to deny patient care. IPAs agree to determine what medical care an individual is entitled to receive in exchange for payments from the insurance company. 

One such payment is known as a capitation payment. The IPA receives these payments regardless of whether a member accesses medical treatments. In other words, Allied Pacific IPA receives payment with no outlay of services for healthy members. On the flip side, a member who has serious medical issues over the course of a year could cost the IPA more than the capitation payment. The IPA then has reason to deny healthcare claims for that member. Similar in nature to capitation payments are risk-sharing pools that limit the use of specific medical services. 

Insurance companies often hold back a percentage of capitation payments at the start of each new year, placing that money in a risk-sharing pool. If the actual costs at the end of the year are more than were held back, the IPA is forced to pay a portion of those excess costs. When the actual costs are less, the IPA receives a percentage of that money. If several members spend a considerable time in the hospital, the IPA may try to deny hospital care to those members. In some IPAs, the physicians have ownership interests, receiving bonuses based on yearly profits. As you might imagine, this results in more incentive to deny healthcare to members.  

What Should You Do if Your Allied Pacific IPA of California Insurance Claim is Denied?

If you receive a denial from Allied Pacific IPA or the insurance company, you have options. If the denial is not directly from your IPA physician, you can have your doctor write a letter detailing why the medical procedure or treatment is necessary. You can file an internal appeal with your insurer, asking it to take another look at the claim and reconsider the denial. If you are unsuccessful with an internal appeal, you can file an external appeal with a neutral third party. 

IPA healthcare claim denials tend to be more complex. You will be required to exhaust every administrative remedy provided under Medi-Cal. As an example, if your IPA requires step therapy, you could benefit from speaking to an experienced health insurance claim denial attorney from the Law Offices of Scott Glovsky. 

Our firm helps members with Medi-Cal Managed Care Plans that also have a private insurance company involved such as an Anthem Blue Cross Medi-Cal Managed Care Plan, Promise Health Plan, Health Net Medi-Cal Managed Care Plan, Kaiser Medi-Cal Managed Care Plan, Health Net Medi-Cal Managed Care Plan, Molina Medi-Cal Managed Care Plan, and others. 

Attorney Scott Glovsky will work hard on your behalf to turn a denial into an approval. Scott and his legal team deal with big insurance companies and IPAs virtually every single day. Scott is a well-seasoned trial attorney – one that even the biggest insurance company does not want to go up against in court. You deserve an advocate who will fight for your health and your future, and Scott Glovsky is that advocate. 

How the Law Offices of Scott Glovsky Can Help with a Preferred IPA of California Denial

Attorney Scott Glovsky and his legal team are highly regarded in the industry. We fight insurance companies and IPAs that delay or deny critical care and are zealous patient advocates. We want our clients to understand their rights under California’s Timely Access to Care laws and the Knox-Keen Act. When there is clear evidence of bad faith insurance practices, we will file a lawsuit, push for a resolution in court, or negotiate a settlement. 

Feeling helpless and hopeless is normal if you have received an Allied Pacific IPA denial. While it may seem as though you have few options, this is not the case. Take the first step by speaking to Attorney Scott Glovsky.  An Allied Pacific IPA is not the end of the matter. Attorney Scott Glovsky will ensure you are treated with respect and dignity. Contact the Law Offices of Scott Glovsky.