Doctor’s Complaint: CalOptima Coverage ‘Made Me Worse’

Dr. Amy Cullen
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When Dr. Amy Cullen reviewed a recent federal audit criticizing Orange County’s managed health care plan for jeopardizing the healthcare of 16,000 seniors, she saw herself.

Even though she only is 44 years old, she said the problems cited in the federal audit of CalOptima — the county’s health plan for low-income recipients of both federal Medicare and state Medi-Cal health programs — mirrored her own two-year struggle against the $1.5-billion public insurance agency.

“During the first year of my coverage, I think I filed maybe 14 grievances, because I wasn’t getting the care that I needed,” said Cullen, a physician and Costa Mesa resident who came under CalOptima coverage in 2012 after losing her private health insurance when her lupus symptoms worsened.

A scathing November 2013 federal audit criticized CalOptima for improperly denying prescriptions and medical services in a program designed primarily for elderly members.

The audit of the 16,000-member OneCare program cited a “serious threat to the health and safety” of participants.

Among other findings, auditors cited “widespread and systemic” failures, including denial of prescriptions, even when the drugs were covered by the plan; refusing to pay for emergency services; failure to pay medical providers on a timely basis; and numerous failures in allowing patients and doctors to appeal denials of coverage and other problems.

Now state auditors are checking whether those problems are systemwide.

Cullen said state regulators should be keeping a closer eye on the agency.

“I thought that it [the federal audit] was very interesting, because the things they were cited for are the exact same problems that I experienced,” said Cullen, a board-certified family medicine specialist.

“They denied coverage for things they should have covered. They would randomly increase my share of costs from zero to $1,200 a month. I’ve got stacks of letters from them denying things they should have covered,” she said, providing copies of letters to Voice of OC.

CalOptima officials said confidentiality laws prevent them from discussing Cullen’s case.

Cullen’s experience with CalOptima came at a time when it had just brought in a new company to manage its prescription drug program as it was losing about two dozen top and key executives amidst the turmoil created by Supervisor Janet Nguyen’s takeover of the CalOptima board of directors.

Nguyen and CalOptima officials have attempted to downplay the federal audit – arguing that care outcomes in 2012 were good. Cullen said such statements miss the point.

When sick people have prescriptions and services denied, they get worse. Cullen, who publicly addressed the CalOptima board about her case on March 6, points to her own condition as an example.

“I think I have a unique background to give some feedback about my care,” she said of her two years on the plan, saying it kept her focused on administrative denials rather than healing. “I was constantly dealing with some issue involving CalOptima,” Cullen said.

At the CalOptima board meeting she publicly described a tough two years with CalOptima coverage, dealing with dozens of delays on pharmacy prescriptions, denials of services and questionable referrals.

“This has been very, very frustrating for me,” Cullen said.

(Click the play button below to hear her comments.)

CalOptima Chairman Mark Refowitz agreed to address Cullen’s issues personally, and Nguyen asked staff to update the full board on Cullen’s case.

Cullen told CalOptima board members about a life-changing incident triggered by a denial of services.

Cullen noted she had been getting regularly scheduled Botox injections for numerous months that helped her control serious migraines. Botox, now known largely for its cosmetic application, is primarily used as a neurological pain and muscle medication.

Then in November 2013, “less then 24 hours before my appointment, suddenly, they denied coverage,” Cullen said. “They said I didn’t need to see my neurologist and I didn’t need to have my injections.”

In its denial, CalOptima wrote, “The requested service does not require a tertiary [highly specialized] level of care as it can be provided by a secondary medical care provider with the community.”

Cullen appealed formally. And after a month, the decision was overturned, according to records that Cullen shared with Voice of OC.

But in the meantime, Cullen’s condition worsened significantly.

“I started having a flair-up of my lupus central nervous symptoms. … I was having trouble walking, I was having trouble with my vision and I was having continuous migraines,” she said.

After she once again was allowed to get the injections for migraines, Cullen saw her regular neurologist, who noticed significant weakness in her right arm.

“I was having clumsiness, I was dropping things with my right arm and I had never had that problem before,” she said.

Cullen said her neurologist thought she might be having a stroke. She was admitted to the hospital, where, over three days, her symptoms were stabilized.

Yet after getting out of the hospital, CalOptima denied the admission, meaning UC Irvine Medical Center had to absorb the costs.

“Your care and treatment could have been handled in the ER or as an outpatient basis,” stated a CalOptima letter dated Jan. 16. “Therefore CalOptima cannot approve your inpatient stay at UCI.”

“So they made me worse and now they are denying the hospitalization they caused,” Cullen said.

“I’m still fighting it,” Cullen said. “I don’t know what’s going to happen.”

After she spoke in public to the CalOptima board of directors this month, CalOptima officials said they again would review the hospital admission decision. Cullen said CalOptima later called to tell her the review has been boosted from the staff level to the desk of CalOptima’s chief medical officer, Dr. Richard Helmer.

She’s also asking state officials for an independent medical review. Cullen said state officials should dig further.

She was enrolled in the CalOptima Care Network, a program designed for patients with major medical problems.

“I’m supposed to have good access to care. I can only imagine what’s happening to people who aren’t in my program. If I’m not getting the care I need, I can only imagine what they must be going through,” Cullen said.

And when there’s a problem, Cullen said, talking to CalOptima isn’t easy.

“I had countless conversations, countless conversations. It was exhausting. I got nowhere. … I would talk to grievance specialists. I would get these letters where they would just parrot back my complaints. And I’ve got stacks of letters. I got exhausted that by the second year, I got exhausted. I stopped fighting. I was just so sick.”

Today, Cullen has moved into a Medicare program for adults with permanent disabilities and said she is happy because she is getting the care she needs. Ironically, Cullen laughs that CalOptima officials tried to recruit her to the OneCare program that just received the critical audit.

Cullen said that would be “a cold day in hell.”

Yet given her medical background and patient experience, Cullen reached out to media because she said many poor residents on CalOptima might not know enough to complain.

She urges state officials to take a close look.

“Clearly this is a problem. And I think it’s a widespread program with CalOptima. I think they’re doing it with all their programs. … They have a problem. Something is wrong in their system,” she said.

Cullen likens CalOptima to a hardcore HMO private-sector company.

“I think they repeatedly deny things, and they wear out their members. I mean, when you keep hitting roadblocks again and again, and you’re sick. After a while, you get beaten down, and it’s too hard to fight. I think that happened to me.”

“After the first year, I had so many letters I’d written the first year trying to appeal. And then the second year, I think I just felt worn out.”

“I just couldn’t do it anymore.”

Please contact Norberto Santana Jr. directly at nsantana@voiceofoc.org and follow him on Twitter: twitter.com/norbertosanana.

Please contact Tracy Wood directly at twood@voiceofoc.org and follow her on Twitter: twitter.com/tracyVOC

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