The California Department of Managed Health Care announced Wednesday that it had leveled a $5 million fine against Anthem Blue Cross, saying the insurer demonstrated a systemic pattern and practice of failing to identify, process and resolve grievances for enrollees in its managed-care plans.
“The grievance process is fundamental to protecting consumers’ health-care rights and ensuring consumers receive the care they need,” said DMHC Director Shelley Rouillard. “Anthem Blue Cross’ failures to comply with the law surrounding grievance and appeals rights are longstanding, ongoing and unacceptable. The plan must correct the deficiencies in their grievance and appeals system and comply with the law.”
Including this latest enforcement action, DMHC leaders said, the agency has fined Anthem Blue Cross $11.66 million for grievance system violations since 2002. This figure far outstrips the $1.76 million in fines leveled against Blue Shield of California, the insurer with the next highest enforcement actions in this category.
In a statement emailed Wednesday, Anthem spokeswoman Suzanne Meraz said: “Anthem strongly disagrees with the DMHC’s findings and the assertion that these findings are systemic and ongoing. Unfortunately the DMHC has not fulfilled its obligations to clarify the regulatory standards and definitions being applied in the audits, despite multiple requests from Anthem to do so.”
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Meraz said Anthem has taken responsibility for errors in the past and it is taking steps to address legitimate findings in the audit. Anthem has made significant changes in its grievance and appeals process, Meraz said, and it has invested in system improvements to put the needs of its members first.
“Anthem Blue Cross remains committed to providing access to quality, affordable health care, and recognizes a consumer-friendly grievance and appeals process is part of that commitment,” Meraz stated.
Officials with the DMHC said that, as of June of 2017, Anthem Blue Cross reported serving nearly 4 million Californians in its managed care plans. To illustrate the type of grievances that were not handled appropriately, DMHC officials shared the case of an Anthem Blue Cross enrollee who was diagnosed with a serious condition. The insurer pre-authorized extensive surgery and reconstruction for the enrollee, agency officials said, but then denied the claim when it was submitted by the enrollee’s provider.
“In an effort to resolve the issue, the enrollee, as well as the enrollee’s provider, broker, and spouse made 22 calls to the plan,” the DMHC statement said. “Even after the 22 calls, Anthem Blue Cross failed to recognize or resolve the enrollee’s complaint.”
Anthem Blue Cross paid the claim more than half a year after the treatment, after the enrollee sought assistance from the Department of Managed Health Care. Health plans are required to have grievance and appeals systems to resolve consumer complaints, and they must recognize expressions of dissatisfaction as grievances or complaints.
If consumers are not satisfied with their health plan response to a grievance or have been in their plan’s grievance system for 30 days, they should contact the DMHC Help Center at 888-466-2219 or online at www.HealthHelp.ca.gov.