The California Department of Managed Health Care (“DMHC”) has issued a $5 million fine against Blue Cross of California (Anthem Blue Cross) for what it characterized in a statement as “systemic grievance system violations.”
According to the DMHC, Anthem Blue Cross demonstrated “a pattern and practice of failing to identify, timely process and resolve enrollees' grievances.” Moreover, the DMHC said, Anthem Blue Cross failed to fully and timely provide information to the DMHC during the investigation of member complaints.
“The grievance process is fundamental to protecting consumers' health care rights and ensuring consumers receive the care they need,” said the DMHC's 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.”
The DMHC said that its enforcement action was the result of deficiencies identified in DMHC surveys and 245 specific grievance system violations identified by the DMHC's help center during the investigation of consumer complaints from 2013 through 2016. Including this fine, the DMHC has fined Anthem Blue Cross $11.66 million for grievance system violations since 2002.
One example cited by the DMHC of the failures of the Anthem Blue Cross grievance system involved an enrollee who was diagnosed with a serious condition. Anthem Blue Cross provided pre-authorization for extensive surgical intervention and reconstruction to treat the enrollee. Anthem Blue Cross denied the claim when it was submitted by the 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. Even after the 22 calls Anthem Blue Cross failed to recognize or resolve the enrollee's complaint, according to the DMHC.
Under California law, plans are required to recognize an expression of dissatisfaction as a grievance, or complaint. Instead, calls to Anthem Blue Cross' customer service system resulted in repeated transfers, as well as unfulfilled promises that the plan's representatives would return calls. 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.
Steven A. Meyerowitz
Steven A. Meyerowitz, a Harvard Law School graduate, is the founder and president of Meyerowitz Communications Inc., a law firm marketing communications consulting company. He may be contacted at [email protected].