Blue Shield Fined $45,000 By DMHC

Blue Shield of California was fined $45,000 by the Department of Managed Health Care last month for five separate violations of the Knox-Keene Act, records show.

The largest fine against the San Francisco-based insurer was $15,000 for a 2012 incident where an enrollee was billed for mental health services that were originally rendered by an in-network provider which had been transitioned out of network.

The DMHC had concluded that Blue Shield both failed to respond to the enrollee’s grievance in a timely manner, and did not respond to the agency within the proscribed period of time when it requested details about the incident. And when Blue Shield responded to the DMHC, it did not provide all of the information that was requested.

Blue Shield was also fined $10,000 for insisting on prior authorization from a provider to render emergency services;$10,000 for not responding to an enrollee grievance in a timely fashion; $5,000 for not providing complete information to the DMHC about a network grievance; and $5,000 for failing to timely respond to a formulary issue.