Brief

California slaps Blue Shield, Anthem with fines over inaccurate provider directories

Dive Brief:

  • On Tuesday, the California Department of Managed Health Care (DMHC) announced it issued fines against Blue Shield of California ($350,000) and Anthem Blue Cross ($250,000) for “inaccurate provider directories.”
  • Between January and May 2014, the DMHC Help Center received numerous complaints from Blue Shield and Anthem individual market enrollees who could not find a primary care physician in their area or alleged they had been misled by inaccurate health plan provider network directories.
  • In response, the agency via surveys found 18.2% of the physicians listed in Blue Shield’s provider directory were not at the location listed and 12.5% of the physicians were not at the location listed in the Anthem provider directory.

Dive Insight:

The survey also found of those who were at the location listed, 8.8% were not willing to accept members enrolled in Blue Shield’s Covered California products, despite being listed as doing so. For such Anthem providers, 12.8% were not willing to accept patients enrolled in the insurer’s Covered California products, despite being listed as doing so.

In addition to DMHC’s action, Blue Shield and Anthem both have consumer lawsuits still pending, reports the Los Angeles Times.

“An important element of access is ensuring enrollees have accurate provider directories,” said DMHC Director Shelley Rouillard in a prepared statement. “The DMHC has taken enforcement action and fined Blue Shield and Anthem due to unacceptable inaccuracies in their directories. These inaccuracies limited enrollee access to care that resulted in an unacceptable consumer experience and must be fixed.”

Blue Shield has already reimbursed more than $38 million to enrollees who incurred out-of-network costs, according to the statement. “Both Blue Shield and Anthem will report to the department the final number of enrollees reimbursed and the total amount reimbursed.”

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