CalOptima Reverses Controversial Denial of Doctor’s Hospitalization

Dr. Amy Cullen
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Dr. Amy Cullen, a disabled family physician and CalOptima member who severely criticized operations at the county health plan for low-income, disabled and elderly residents, said Wednesday the agency has reversed itself and now is approving her hospitalization last year at UC Irvine Medical Center.

Cullen was the subject of a Voice of OC report last month that raised questions about whether a searing federal audit released in January could be an indicator of greater problems at the agency regarding improper denials of prescriptions and medical procedures for patients.

Cullen said she received a telephone call Tuesday from CalOptima’s Chief Medical Officer, Dr. Richard Helmer, who told her they had sent her case to an outside neurologist for an independent review.

That doctor agreed with Cullen that her hospitalization was appropriate, she said Helmer told her.

“Actually, he was really nice,” said Cullen, who spent much of 2012 and 2013 wrestling with CalOptima vendors or agency staff who denied prescriptions, among other issues, but wound up approving them after she fought through numerous appeals.

“Of everybody I’ve dealt with at CalOptima, he was the most intelligent and seemed like he was actually going to change things,” Cullen said.

A CalOptima spokeswoman said Wednesday that privacy laws prohibited the agency from discussing an individual’s case.

Cullen of Costa Mesa began coverage by CalOptima in 2012, because she developed pneumonia as a complication of lupus, which left her unable to work. As of January, she was transferred to a federal Medicare program for adults with permanent disabilities.

But for roughly two years before that, she was enrolled in the CalOptima Care Network, a program designed for patients with major medical problems.

Cullen was hospitalized for three days in late 2013 after her neurologist thought she might be having a stroke.

The symptoms, which were stabilized while she was in the hospital, were brought on, she said, by an earlier CalOptima denial of a prescription she used to mitigate migraines. The prescription denial came less than 24 hours before she was to see her neurologist for a injection and it wasn’t renewed until her appeal was approved a month later.

Cullen said she told Helmer CalOptima should change its policy so that if a prescription is denied, the patient gets a week’s supply to carry through while the patient has a chance to appeal.

“I really hit that,” she said.

She also urged Helmer to have cases reviewed by medical professionals who know the medical issues involved.

In her case, she said her hospital stay initially was denied by a lung specialist, not a neurologist.

Even though it was UCI, not Cullen, who had to absorb the hospital costs after her stay was denied, she continued to fight the decision.

Why?

“I thought it was the right thing to do,” she said. “It just upset me they [CalOptima] were not doing the right thing. That bothered me. It’s all related to people not getting the care they need.”

Cullen, a board-certified family medicine specialist, said if her illness didn’t absolutely prevent it, she wished she could go to work for CalOptima.

“I would like to help them,” she said. “I feel bad for the people who use CalOptima.”

The $1.5-billion agency, the county’s largest, is being audited by both federal and state officials to determine whether its overall operations, including that of its prescription vendor, are being run right.

In January, auditors for the Centers for Medicare & Medicaid Services stopped CalOptima from enrolling new applicants in the 16,000-member One Care program for largely elderly, low-income patients and said the program posed a “serious threat to the health and safety” of participants.

The performance issues were quickly corrected, according to CalOptima executives, but federal auditors will return during the summer to re-examine the program.

In addition, state auditors are looking into other CalOptima programs to see whether similar or other problems exist.

CalOptima provides federal Medicaid and state Medi-Cal coverage to about 470,000 county residents, most of them children.

Cullen’s CalOptima experience coincided with months of top executive turnover, when all the main leaders, including chief executive officer, chief financial officer, chief medical officer and chief operating officer, left for private industry or other government agencies.

Their moves came in the wake of a takeover of the CalOptima board of directors by Supervisor Janet Nguyen, who led an ouster of the old board in 2011.

Nguyen, who is now vying for the 34th State Senate District, raised eyebrows amongst her colleagues after being appointed to oversee CalOptima for her aggressive fundraising and simultaneous reshaping of CalOptima’s governing ordinance.

Since coming onto the board and reshaping its structure in favor of hospitals, medical providers and county agencies, Nguyen’s contributions from the health industry spiked from around $15,000 to more than $95,000.

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

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