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Thursday, November  10, 2016

 

DMHC Fines Anthem Blue Cross $650,000 for Pattern of Grievance System Violations

(Sacramento) – The California Department of Managed Health Care (DMHC) announced today that it took enforcement action including a $650,000 fine against Blue Cross of California (Anthem Blue Cross) for failing to identify, timely process and resolve enrollees’ grievances. Anthem Blue Cross also failed to fully and timely provide information to the Department during the investigation of member complaints.

“The grievance process protects enrollees’ rights and helps ensure enrollees receive the care to which they are entitled,” said DMHC Director Shelley Rouillard. “Anthem Blue Cross has repeatedly failed to comply with requirements for properly identifying, acknowledging and resolving enrollee grievances within the required timeframes.“

In this instance the DMHC identified 58 cases involving 109 violations where Anthem Blue Cross deprived members of their grievance and appeal rights. Since 2003, the DMHC has fined Anthem Blue Cross over $6 million for approximately 872 grievance system violations. This includes a $415,000 fine earlier this year.

Health plans’ grievance programs exist to assist consumers in resolving issues with their health plans. A health plan’s grievance program informs enrollees of their full grievance and appeal rights and protections afforded to them under the law, such as the right to pursue an Independent Medical Review or file a complaint with the DMHC if they are dissatisfied with the health plan’s decision.

A robust grievance program allows health plans to track and trend grievances for the purpose of uncovering systemic problems, thereby providing the opportunity for quality improvement.

In California, health plan members have many health care rights including the right to know why a plan denies a service or treatment, and the right to file a grievance if they disagree. Members also have the right to file a complaint and request an Independent Medical Review from the DMHC.

Members who experience difficulty accessing care or have questions about their health plan’s grievance and appeals program should contact the DMHC Help Center for assistance at 1-888-466-2219 or www.HealthHelp.ca.gov.

For additional information on this enforcement action visit: http://wpso.dmhc.ca.gov/enfactions/docs/2742/1478802681115.pdf

About DMHC:

The DMHC protects the health care rights of more than 25 million Californians and ensures a stable health care delivery system. The Department has helped more than 1.7 million Californians resolve health plan problems through the Help Center. Information and assistance is available at www.HealthHelp.ca.gov or by calling 1-888-466-2219


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