DMHC Fines Anthem Blue Cross $690,000 for Delaying Reimbursements to Providers & Members

Department of Managed Healthcare
January 4, 2024

DMHC Fines Anthem Blue Cross $690,000 for Delaying Reimbursements to Providers & Members

SACRAMENTO – The California Department of Managed Health Care (DMHC) has taken enforcement action against Blue Cross of California (Anthem Blue Cross) including a $690,000 fine for failing to timely reimburse providers and health plan members for services provided. The plan agreed to pay the fine and implement corrective actions.

“The DMHC is committed to protecting consumers’ health care rights and ensuring health plan members have access to appropriate health care services when they need it,” said DMHC Director Mary Watanabe. “The Independent Medical Review program is an important consumer protection to make sure members can access needed health care services, and health plans are required to timely implement decisions in these cases. Through this settlement agreement, Anthem Blue Cross has agreed to take corrective actions to timely implement Independent Medical Review decisions.”

WHY THIS MATTERS TO CALIFORNIANS: Health plan members have the right to appeal to the health plan’s regulator to request qualified medical experts review their plan’s denial of services and determine whether disputed health care services were improperly denied. This appeal is called an Independent Medical Review, where health care professionals completely independent of the health plan review the appeal. When a plan’s denial is overturned through an Independent Medical Review, the law requires plans to reimburse the provider or member for past services, and authorize future services, within five working days after a plan receives the decision.

BACKGROUND: Between June 2021 and December 2021, the plan failed to timely reimburse the provider or health plan member after receipt of an Independent Medical Review decision that overturned the plan’s initial denial of services to the health plan member.

The Department’s enforcement action involved cases for nine health plan members who sought Independent Medical Reviews through the DMHC Help Center. These cases covered a variety of disputes with Anthem Blue Cross, including denials involving the medical necessity of residential treatment center services for behavioral health matters, denials to pay urgent care claims, and denials to cover preventative tests and certain medications. The delay in payment spanned 3 to 36 days.

HEALTH PLAN CORRECTIVE ACTIONS: In addition to paying the $690,000 fine, Anthem Blue Cross implemented several corrective actions, including improving its policies and procedures involving Independent Medical Review decisions. The plan dedicated resources to adjusting affected claims within the next business day after a relevant decision is received and improved communication with out-of-network providers. Also, the plan monitors claims to ensure they are completed in a timely matter and conducts ongoing training to ensure employee compliance with these policies and procedures.

WHAT HEALTH PLAN 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 1-888-466-2219.

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About DMHC:
The DMHC protects the health care rights of 29.7 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted 2.8 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.

Read More at the Department of Managed Healthcare.