Heritage Provider Network IPA

Receiving a Heritage Provider Network IPA denial can leave you frustrated and anxious about your own health or that of a loved one. An Independent Practice Association (IPA) may also be known as an Independent Provider Association or an Independent Physician Association. IPAs are networks of doctors with their own practices. An IPA may have a variety of practitioner types, and some can include physicians, hospitals, imaging centers, and urgent care clinics. 

IPAs contract with managed care organizations (HMO, PPO, POS plans) and health insurance companies, allowing physicians to remain independent while accessing a variety of benefits. In 2022, almost half of all California physicians were members of an IPA as they sought to enhance patient care, reduce overhead costs, and increase operational efficiency. As a group, an IPA can provide more services for patients and have expanded negotiating power with health insurance companies. 

Regardless of how you get your health care, you have options when facing a Heritage Provider Network IPA claim denial. The best choice you can make in such a situation is to speak to an exceptionally experienced insurance denial attorney from the Law Offices of Scott Glovsky. Scott wrote the book – Fighting Health Insurance Denials: A Primer for Lawyers – which has become the training manual for law firms and lawyers. Scott fights for justice for his clients every day, forcing insurance companies to treat clients with dignity and respect. 

Overview of Heritage Provider Network IPA of California

Heritage Provider Network IPA (AKA HPN IPA) has a massive patient base with a wide geographic scope. It also has had repeated issues with violations of timely access to care. Heritage Provider Network IPA serves Los Angeles County, San Bernardino County, and Riverside County. HPN is one of the largest physician organizations in the state, coordinating care through various affiliated IPAs, including Regal Medical Group, Lakeside Community Healthcare, and others.  

HPN has a dedicated health channel that offers extensive coverage of many of Dr. Merkin’s activities and interviews, along with important community outreach programs. Touchpoints newsletters help further inform policyholders of their healthcare options and the best ways to stay healthy. HPN began in 1979 when founder Dr. Richard Merkin was asked by a local health plan to start a medical group in a formerly underserved area. Since that time, HPN has strived to provide quality, cost-effective healthcare for members. 

Overview of Heritage Provider Network IPA of California Claim Denials

Heritage Provider Network IPA of California received a Department of Managed Healthcare 2023 violation for failure to ensure timely access to care, failing to meet the timely access standards in California for non-urgent primary care, specialty care, and behavioral healthcare services. This is a violation of California Health and Safety Code Section 1367.03. 

Managed care plans and IPAs are required under this statute to provide service within 10 business days for non-urgent specialist appointments, within 15 business days for non-urgent primary care, and shorter times for behavioral health and urgent needs. HPN was required to pay a $127,500 administrative fine, submit a detailed compliance plan, implement oversight systems to track appointment wait times, and prevent recurrences of these violations. 

Patients who are required to wait for long periods of time before being seen by a physician have a high risk of worsening conditions, increased frustration, loss of trust in the healthcare system, and experience unacceptable delays in receiving necessary medical care. This is especially serious for those with chronic health conditions or behavioral health conditions like depression, anxiety, alcohol use disorder, and others.   

What Are the Most Common Reasons Given by Heritage Provider Network IPA of California for Insurance Claim Denials?

Common claim denial reasons Heritage Provider Network IPA of California gives are often related to coverage disputes. The insurer may deny a claim, arguing that the treatment was not medically necessary, even when an IPA physician deems it necessary, or the IPA itself could deny the service, but generally only denies more costly procedures, such as diagnostic tests, specialist referrals, or other expensive treatments. 

Certain procedures may require pre-authorization, which can lead to confusion regarding whether the insurer or the IPA is responsible for the approval. These behaviors leave the patient without necessary care, confused, and unsure how to get the medical care they need. In some cases, HPN could wrongfully deny a claim, known as a bad faith denial. Policyholders can assert their rights under California law if this is the case. 

There are often deeper reasons policyholders may receive claim denials that have to do with the contracts[SG1]  entered into between Heritage Provider Network IPA and health insurers, which essentially change the IPA into a small insurance company with financial incentives to deny patient care. In exchange for insurer payments, IPAs agree to determine what medical care an individual needs or is entitled to receive. Specific incentives include capitation payments, which are fixed monthly payment amounts for each member in an IPA. 

The IPA receives capitation payments regardless of whether the member utilizes medical treatments. Heritage Provider Network IPA receives payment with no outlay of services for a member who is healthy all year and does not use his or her healthcare coverage. A member who has serious medical issues during a given year could cost the IPA more than the capitation payment, leading the IPA to deny healthcare claims for that member. Risk-sharing pools are similar in nature to capitation payments, limiting the use of specific medical services. 

Insurers may hold back a percentage of capitation payments at the start of each new year, placing the money in a risk-sharing pool. At the end of the year, if the actual costs are more than what was held back, the IPA must pay a portion of the excess costs. If the actual costs are less than the amount held back, the IPA receives a percentage of that money. If several members spend a considerable time in the hospital, the IPA may attempt to deny hospital care to these members. Since some physicians also have ownership interests in the IPA and receive bonuses based on yearly profits, there is even more incentive to deny healthcare to members

What Should You Do if Your Heritage Provider Network IPA of California Insurance Claim is Denied?

IPA healthcare claim denials tend to be more complex, requiring members to exhaust every administrative remedy provided under the Medi-Cal appeal process. For example, if your IPA refuses to approve a treatment or tells a member to go through step therapy, there is a significant benefit in 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. 

We understand every nuance of these claim denials and will work hard to turn a denial into an approval. Attorney Scott Glovsky routinely deals with big insurance companies and IPAs, which significantly increases your chances of a positive outcome following a denial. Attorney Scott Glovsky is here for you if you want an attorney who believes in justice for everyone and never hesitates to go up against a big insurance company. 

How the Law Offices of Scott Glovsky Can Help with a Heritage Provider Network IPA of California Denial  

A Heritage Provider Network IPA claim denial can leave you feeling hopeless and helpless. If you are ill or have a serious medical condition that would benefit from a specific prescription drug or medical treatment, it can feel like the end of the world to receive a denial. When you are left feeling alone with no way to change the outcome, do not give up. There is hope. Attorney Scott Glovsky and his knowledgeable legal team are ready and able to take on Heritage Provider Network IPA. 

For over twenty-five years, Scott has been fighting for his clients. While some cases are settled out of court, it is imperative to have an attorney with vast courtroom experience, like Scott Glovsky. When the other side recognizes they will end up in a courtroom across from a sharp, highly skilled trial lawyer, they are much more likely to offer a reasonable settlement. Attorney Scott Glovsky tries cases – and wins. 

Scott has received the California Lawyer Magazine’s California Lawyer of the Year Award and the Consumer Attorneys of California’s Street Fighter of the Year Award. He has also been designated as a Super Lawyer every year since 2006 and has been recognized by Best Lawyers every year since 2016. For a lawyer who will aggressively fight for your future, contact the Law Offices of Scott Glovsky.