Dive Brief:
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The California Department of Managed Health Care (DMHC) fined Anthem Blue Cross $5 million for “systemic grievance system violations.”
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In announcing the fine on Wednesday, the DMHC said “Anthem Blue Cross has demonstrated a pattern and practice of failing to identify, timely process and resolve enrollees’ grievances.” It also “failed to fully and timely provide information to the department during the investigation of member complaints.”
- In a statement reported by Kaiser Health News, Anthem acknowledged some errors, but disagreed that the issues are “systemic and ongoing.” Anthem said it will contest the fine.
Dive Insight:
The DMHC said the fine comes after deficiencies were found in DMHC surveys and “245 specific grievance system violations identified by the DMHC Help Line” between 2013 and 2016.
Including this latest penalty, DMHC has fined Anthem $11.66 million for grievance system violations since 2002, according to the DMHC. Those violations include two fines in 2016 that totaled more than $1 million.
“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,” DMHC Director Shelley Rouillard said in a press release.
The state department highlighted an example of the reported failures in Anthem’s grievance system. The DMHC said an Anthem member with a serious condition received pre-authorization from the payer for “extensive surgical intervention and reconstruction.” However, Anthem later denied the claim.
The member, provider, broker and spouse all called Anthem a total of 22 times to report the problem, but Anthem “failed to recognize or resolve the enrollee’s complaint,” said the DMHC.
The DMHC said California law requires payers to recognize grievances and complaints, but Anthem’s customer service transferred calls repeatedly and allegedly made unfulfilled promises to return phone calls, said the DMHC.
“It was not until the enrollee sought assistance from the DMHC, more than half a year after the treatment, that Anthem Blue Cross finally paid the claim,” the DMHC said.
In addition to fines related to grievances, the DMHC also fined Anthem $250,000 for inaccurate provider directories in 2015. At that time, the department additionally fined Blue Shield of California $350,000 for the same issue.
Anthem is not the first large payer to feel the wrath of the DMHC this year. The department cited Kaiser Permanente in June for allegedly not providing appropriate access to mental healthcare. California requires payers provide patients access to a medical appointment within 48 hours for an urgent need and 10 business days for a non-urgent issue.
The following month, the DMHC and Kaiser Permanente, which was also fined $4 million for similar reasons in 2013, came to an agreement to “correct identified issues with the plan’s oversight of and access to behavioral health services.”