Monday, December 16, 2024
DMHC Fines Anthem Blue Cross $3.5 Million for Mishandling Member Complaints
(Sacramento) – The California Department of Managed Health Care (DMHC) fined Blue Cross of California (Anthem Blue Cross) $3.5 million for failing to handle health plan member complaints, also known as grievances or appeals, in a timely manner.
“The health plan grievance and appeals process helps to ensure members receive all medically necessary care,” said DMHC Director Mary Watanabe. “Members must receive timely notice of a plan’s decision and their rights to appeal the plan’s decision. A health plan’s grievance process should inform members of their full grievance and appeal rights and the protections afforded to them under the law, such as the right to file an appeal with the DMHC.”
INVESTIGATION: The DMHC launched an investigation into the plan after Anthem Blue Cross reported a high number of late standard grievance acknowledgment and resolution letters. California law requires health plans to acknowledge receipt of a standard grievance within five calendar days. The Department found the plan sent 11,670 late grievance acknowledgement letters to health plan members between July 2020 through September 2022. Among those letters, 447 were more than 51 days late and 3,657 were not sent at all.
In addition, the plan failed to resolve grievances and issue written responses in a timely manner. Under the law, plans must resolve a standard grievance within 30 days and send a written resolution to the member. The plan sent 4,049 late grievance resolution letters, including 1,634 that were more than 51 days past due.
The plan admitted it failed to follow the law and has paid the $3.5 million fine. In addition, the plan has stated it implemented improvements to its grievance and appeals process, including additional training and procedures to meet grievance standards and timelines.
WHAT MEMBERS CAN DO: The DMHC encourages health plan members experiencing issues with their health plan, including denials, delays or modifications of requested health care services, to file a complaint, also called an appeal or grievance, with their health plan. If the member does not agree with their health plan's response or the plan takes more than 30 days to respond to the grievance, the member should contact the DMHC Help Center. If a health plan member is experiencing an urgent issue, they should contact the DMHC Help Center immediately.
Health plan members can file a complaint or apply for an Independent Medical Review with the DMHC Help Center at www.DMHC.ca.gov or call 1-888-466-2219.
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About DMHC:
The DMHC protects the health care rights of more than 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.9 million Californians to resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.DMHC.ca.gov or call 1-888-466-2219.