Friday, November 22, 2024
DMHC Fines Blue Cross of California $500,000 for Failing to Acknowledge Complaints, Impacting a Member’s Cancer Care
(Sacramento) – The California Department of Managed Health Care (DMHC) took enforcement action, including $500,000 in fines, against Blue Cross of California (Anthem Blue Cross) for failing to provide basic health care services and acknowledge complaints filed by a health plan member during cancer treatment. The plan has agreed to pay the penalty, repay providers, and take corrective action to improve communication with members filing grievances.
“No one should have to call their health plan 17 times to get answers about coverage for a potentially lifesaving treatment, especially someone fighting cancer,” said DMHC Director Mary Watanabe. “Health plans must resolve grievances in a timely manner and members should not have to call back numerous times to resolve a problem.”
MEMBER PROTECTIONS: Health plan members have a right to file a complaint, also known as an appeal or grievance, if they are dissatisfied with their care. California law requires health plans to acknowledge receipt of a standard grievance within five calendar days, resolve the grievance within 30 days, and send a written resolution to the member.
In this case, the plan failed to acknowledge and respond to a total of 17 grievances by the member, who called the plan repeatedly after it failed to cover basic health care services, including hospital-related costs for surgeries. Among those calls, the member contacted the plan 10 times when they learned the plan failed to authorize life-saving chemotherapy. Under the law, the plan should have tracked these issues as urgent grievances and provided an expedited review, since they involved an imminent and serious threat to the health of the patient. Plans are required to acknowledge receipt of an urgent grievance within three days and inform the member of their right to contact the DMHC.
PLAN TAKES CORRECTIVE ACTION: Anthem Blue Cross has acknowledged their failure to comply with the law and agreed to pay the penalty and complete a Corrective Action Plan (CAP) to settle the issue. The CAP includes training for staff to ensure grievances are correctly identified and out-of-network authorization processes are improved. The plan will also pay the balances owed to the member and providers, including interest.
WHAT MEMBERS CAN DO: 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 complaint, also called an appeal or grievance, 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 fix the problem for non-urgent issues, the DMHC Help Center can work with the member and health plan to resolve the issue. If a health plan member is experiencing an urgent issue, they should 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 call 1-888-466-2219.
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About DMHC:
The DMHC protects the health care rights of more than 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.9 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.DMHC.ca.gov or call 1-888-466-2219.