Thursday, June 9, 2022

DMHC Fines Anthem Blue Cross $1.1 Million, Requires Corrective Actions to Protect Consumers

Anthem Blue Cross Reimburses Enrollees $9.2 million

(Sacramento) – The California Department of Managed Health Care (DMHC) has taken enforcement actions totaling $1,110,000 in fines against Blue Cross of California (Anthem Blue Cross) to protect consumers. The Department's enforcement actions include a fine of $750,000 for incorrectly applying office visit costs to enrollee deductibles impacting 6,561 enrollees from 2015 through 2020, and a fine of $360,000 for failing to mail Explanation of Benefits (EOB) to 363,257 enrollees in 2019. Anthem Blue Cross reported both issues to the Department, and has agreed to pay the fines and complete corrective actions including identifying and reimbursing enrollees impacted by the incorrect office visit costs.

"The DMHC's enforcement actions against Anthem Blue Cross are a strong reminder that the Department will hold health plans accountable to the law, and protect consumer's health care rights," said DMHC Director Mary Watanabe. "These violations had financial impacts to enrollees, and deprived enrollees of information on their rights to file a complaint or apply for an Independent Medical Review with the DMHC Help Center. Anthem Blue Cross has agreed to take corrective actions including reimbursing impacted enrollees and updating the plan’s policies to make sure these issues do not happen again."

The plan was in violation of the law when it failed to properly exclude certain office visits from enrollee deductibles. These office visits included primary care, and behavioral health office visits. The plan agreed to corrective actions including identifying and reimbursing impacted enrollees, which includes reimbursing nearly $9.2 million to 6,561 enrollees.

Health plans are required to issue an EOB to an enrollee to provide information on the plan’s processing of a claim for providing health care services, and to advise the enrollee of any amount the enrollee is responsible for paying. The EOB is an important document for enrollees. With products that have out-of-pocket maximums, enrollees can use the EOB to track amounts paid out-of-pocket for the year. The EOB also includes important information on enrollee rights including appeal rights and language assistance.

In addition to paying a fine, Anthem Blue Cross has agreed to implement several corrective actions including changes to the plan’s policies and procedures to ensure these issues don’t happen again.

The DMHC encourages health plan enrollees having trouble getting the care they need to file a grievance or appeal with their health plan. If the enrollee does not agree with their health plan's response or the plan takes more than 30 days to fix the problem for non-urgent issues, the DMHC Help Center can work with the enrollee and health plan to resolve the issue. The health plan enrollee can file a complaint or apply for an Independent Medical Review (IMR) with the DMHC Help Center at www.HealthHelp.ca.gov or 1-888-466-2219. If a health plan enrollee is experiencing an urgent issue, they should contact the DMHC Help Center immediately. Help on urgent matters is available 24 hours a day, seven days a week.

About DMHC:

The DMHC protects the health care rights of more than 27.7 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.5 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.HealthHelp.ca.gov or call 1-888-466-2219.