In Brief: DMHC Fines Anthem $15,000; ACEP Issues Warning About Emergency Care
DMHC Fines Anthem Blue Cross $15,000 Over Handling Of Enrollee Grievance
The Department of Managed Health Care has fined Anthem Blue Cross of California $15,000 for the way it handled the grievance of a 5-year-old enrollee who suffers from autism.
According to the DMHC, Anthem denied two claims filed by the enrollee. The enrollee's mother filed a grievance with the agency in 2013.
The DMHC found that Anthem did not adequately consider the enrollee's grievance regarding being able to find an appropriate physician within its provider network.
The DMHC also found that in resolving the grievance, Anthem did not submit all relevant pages of the enrollee's evidence of coverage with the agency.
As part of the administrative penalty levied by the DMHC, Anthem agreed to appropriately consider future enrollee grievances and submit evidences of coverage in full.
Anthem has been the health plan most penalized and fined by the DMHC, with 1,005 in total dating back to 2001. Altogether, the DMHC has issued a total of 2,768 administrative penalties against more than 200 health plans, medical groups and individuals.
ACEP Issues Warning About Emergency Care
The American College of Emergency Physicians has issued a warning to California residents about seeking care in the correct setting.
The organization, which represents emergency medicine physicians, launched a campaign with its California chapter in San Diego County to try and encourage patients who need care to seek it in the correct setting as opposed to going straight to a hospital emergency department.
"I treat patients in the emergency department every shift who couldn't access a primary care physician and had no choice but to come to the emergency department for treatment because their condition worsened dramatically,”said Marc Futernick, M.D., a practicing emergency physician in Los Angeles and president of Cal-ACEP.
However, both ACEP and Cal-ACEP appear to be transmitting mixed messages as they launched the campaign, suggesting what a fraught issue seeking care for an injury or illness can be.
Even as the organizations pushed for seeking care in the right setting, they issued a joint statement affirming the rights of patients to seek care in the ER if no other alternative was immediately available.
"Despite the Affordable Care Act and the expansion of Medi-Cal, many patients are having trouble finding physicians willing to take their insurance," said ACEP President Jay Kaplan, M.D. "Emergency visits will continue to increase for many reasons including the nation's growing elderly population and primary care physician shortages. The emergency department is the only place people can get help any time of day or night. It's an incredibly valuable service that we all need to support."
Neither organization issued any guidelines as to how a patient or their family members should evaluate an illness or injury and determine whether it warranted urgent care or a visit to the hospital ER.
