Insurance Update

DMHC Fines Anthem Blue Cross $5 Million for Systemic Grievance System Violations

The California Department of Managed Health Care (DMHC) has taken enforcement action against Anthem Blue Cross for systemic grievance system violations.  According to the DMHC press release, “Anthem Blue Cross has demonstrated a pattern and practice of failing to identify, timely process, and resolve enrollees’ grievances.   Anthem Blue Cross has also failed to fully and timely provide information to the Department during the investigation of member complaints.”  In California, health plan members have the right to know why a plan denies a service or treatment, and the right to file a grievance if they disagree.   According to the DMHC 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 action, which included a $5 million fine, is the result of deficiencies found in DMHC surveys and 245 specific grievance system violations identified by the DMHC help Center during the investigation of consumer complaints from 2013 to 2016.  View enforcement action.

If a consumer is experiencing an issue with their health plan or is having difficulty accessing care, they can file a grievance with their plan. If they are not satisfied with their health plan’s resolution of the grievance or have been in their plan’s grievance system for 30 days, they should visit the DMHC website or  contact the DMHC Help Center for assistance at 1-888-466-2219.