Health care coverage: independent medical review.

Senator Wiener's health care accountability legislation establishes new reporting requirements and financial penalties for California health insurers and service plans with high rates of overturned treatment denials. The measure requires annual reporting of all claims processed, treatment denials, and modifications, categorized by type of care and diagnosis, beginning June 2026.

Under the bill's provisions, insurers and plans must face administrative penalties when more than 50% of their independent medical reviews in any care category result in reversed decisions, applicable to entities with 10 or more reviews annually. Penalties start at $25,000 for first violations, escalate to $50,000-$200,000 for second violations, and reach $500,000 for subsequent infractions. The penalty amounts adjust every five years based on medical care cost inflation beginning in 2031.

The legislation creates dedicated accounts within state funds to collect these penalties - the Managed Care Independent Medical Review Administrative Penalties Subaccount and the Health Insurance Independent Medical Review Administrative Penalties Fund. Upon legislative appropriation, these funds may cover implementation costs and other specified purposes. Both the Department of Managed Health Care and Department of Insurance must analyze the reported data and include findings in their annual reports starting in 2028.