DMHC Fines Anthem Blue Cross $57,500

The Department of Managed Health Care has fined Anthem Blue Cross of California $57,500 in connection with what the agency says were seven incidents where it violated state regulations, primarily involving how it handles enrollee grievances.

The largest of the fines, $18,000, is related to an incident that occurred last year, when an enrollee complained to Anthem they had been placed in the wrong health plan and the wrong level of premiums were being collected. “The plan treated the matter as an inquiry and did nothing further,” the DMHC said in correspondence to Anthem, noting that “where the plan is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance” and appropriate action must be taken.

Another $12,000 fine stems from a 2011 incident when Anthem failed to review two requests for a specialist referral by an enrollee in a timely manner when she complained of hip pain due to a torn labrum. The DMHC eventually intervened and assigned the enrollee to a medical specialist for examination. Anthem claimed the request for a referral did not need to be expedited because the patient did not have a life threatening condition or complain of extreme pain. The DMHC also determined that Anthem did not inform the enrollee of the right to file a grievance.

A $7,500 fine was related to a 2014 incident where an enrollee complained that Anthem cashed a premium check and then cancelled his coverage. The DMHC determined that Anthem was required to treat that incident as a grievance.

The agency also levied four other $5,000 fines related to Anthem not resolving enrollee grievances in a timely manner or properly responding to requests for information.