Friday, January 30, 2026
DMHC fines Anthem Blue Cross $15 million for longstanding & widespread failures with member complaints
Plan must work with an independent auditor to ensure member complaints are consistently & timely resolved
SACRAMENTO - The Department of Managed Health Care (DMHC) has taken enforcement action, including a $15 million fine, against Blue Cross of California (Anthem Blue Cross), for the plan’s longstanding and widespread deficiencies in handling the plan’s member complaints, also called grievances or appeals.
As part of this enforcement action, Anthem Blue Cross will work with an independent auditor for up to four years to ensure the plan consistently and properly handles member grievances.
“This enforcement action is the result of a longstanding and unacceptable pattern by Anthem Blue Cross of failing to appropriately identify, timely process or resolve member grievances,” said DMHC Director Mary Watanabe. “Despite several prior enforcement actions and survey findings by the DMHC, Anthem Blue Cross has repeatedly not resolved the identified failures with its member grievance system for more than 15 years. Anthem Blue Cross must now work with an independent auditor to monitor the plan’s corrective actions to make improvements in their grievance system to protect the rights of their members and comply with the law.”
PROTECTIONS FOR HEALTH PLAN MEMBERS: The health plan grievance and appeals process is an important consumer protection that helps ensure health plan members receive medically necessary care. California law requires health plans to have a grievance and appeal system to timely review, resolve and respond to member complaints in an appropriate manner. Through the grievance system, health plans inform members of their grievance and appeal rights and protections under the law, including the right to file a complaint with the DMHC, and information on how to pursue an Independent Medical Review (IMR) when a request for health care services or medical care is denied, changed or delayed by the health plan.
BACKGROUND: The DMHC has taken numerous enforcement actions against Anthem Blue Cross over the last 15 years for failings in the plan’s grievance system. This includes the following actions with significant fines:
- December 2024: The DMHC fined Anthem Blue Cross $3.5 million for mishandling member complaints. The Department found the plan sent 11,670 late grievance acknowledgment 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.
- November 2024: The DMHC fined Anthem Blue Cross $500,000 in a case where a member’s chemotherapy treatment for cancer was delayed due to the plan’s multiple failures in handling the member’s grievance.
- June 2019: The DMHC fined Anthem Blue Cross $2.8 million for failing to correctly identify and process grievances. The Department identified the plan’s failure to recognize, timely process and resolve member grievances through health plan member complaints to the DMHC Help Center, surveys of the plan’s operations and an investigation by the DMHC Office of Enforcement. This included 246 violations from 2013 through 2016.
- November 2009: The DMHC fined Anthem Blue Cross $2.5 million following an audit, which found among other deficiencies the plan’s grievance system was deficient.
Anthem Blue Cross was required to implement several corrective actions to improve the plan’s grievance system following these previous enforcement actions taken by the Department. However, the DMHC found several repeat deficiencies through the Department’s latest routine medical survey, or audit, of the plan. Among the eight identified Grievances and Appeals deficiencies, the survey found Anthem Blue Cross failed to ensure oral expressions of dissatisfaction are considered as grievances, thereby preventing the plan from ensuring adequate consideration of those grievances. In this finding, the plan did not consistently and accurately identify grievances in nearly half of the cases reviewed (Deficiency 4). Additionally, the plan failed to ensure adequate consideration and rectification of exempt grievances when they were identified in 65% of the cases that were reviewed (Deficiency 10).
The survey findings were referred to the DMHC’s Office of Enforcement for further investigation. The investigation found Anthem Blue Cross has repeatedly failed to timely correct the plan’s grievance deficiencies, in violation of the law.
Under this new enforcement action, Anthem Blue Cross will be required to work with an independent auditor to monitor the plan’s improvements in its grievance and appeals operations. The auditor will report actions taken by the plan to improve its grievance system, and the effectiveness of those actions, directly to the DMHC.
WHAT MEMBERS NEED TO KNOW: 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 grievance, also called a complaint or appeal, 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 can contact the DMHC Help Center. If a health plan member is experiencing an urgent issue, they can 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 by calling 1-888-466-2219.
MORE INFORMATION: More information about Anthem Blue Cross can be found on the health plan dashboard on the DMHC website, including information on the plan’s service area, enrollment and complaints.
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About DMHC
The mission of the DMHC is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system. The DMHC accomplishes this important mission by regulating health plans, enforcing California’s strong consumer protection laws and assisting health plan members. For more information visit www.DMHC.ca.gov.