The California Department of Managed Health Care (DMHC) has reached an agreement with Blue Cross of California (Anthem Blue Cross) to correct the plan’s repeated failures to properly identify and handle enrollee grievances and appeals.
DMHC Reaches Agreement with Anthem Blue Cross to Protect Consumers
“Anthem Blue Cross has agreed to make important consumer-protective improvements to how the plan handles consumer grievances and appeals,” said DMHC Director Shelley Rouillard. “A health plan’s grievance program is vital to ensuring consumers receive the care they need.”
Plan Invests $8.4 Million in Consumer Grievances & Appeals Process, Pays $2.8 Million Fine
In addition to paying a $2.8 million fine, Anthem Blue Cross has agreed to a Corrective Action Plan (CAP) that represents a fundamental shift in how the plan handles enrollee grievances. The plan has committed that once an enrollee call reaches a plan customer service representative, the call will be categorized as a “grievance” by default, rather than an “inquiry.” Misclassifying a grievance as an inquiry denies enrollees of their lawful right to engage in the plan’s and the DMHC’s grievance resolution process and can result in delays or denials in care.
The DMHC took enforcement action against Anthem Blue Cross in 2017 related to this issue, and the plan has invested $8.4 million to make improvements to remedy the violations in its grievances and appeals process. The plan has also committed to ongoing monitoring and training of customer service and grievance staff, and to making continued investments in IT systems to ensure enrollees’ grievances are identified, categorized and handled properly. Anthem Blue Cross will also ensure plan employees are trained to understand when enrollee calls are grievances, which will ensure enrollees are notified of their full appeal rights including the right to contact the DMHC.
The Department identified the plan’s failure to recognize, timely process and resolve enrollee grievances through consumer complaints to the DMHC Help Center, surveys of the plan’s operations and an investigation by the DMHC Office of Enforcement. This included 246 grievance systems violations from 2013 through 2016.
Health plans are required to have grievances and appeals processes to assist consumers in resolving issues with their health plans. A health plan’s grievance program informs enrollees of their full grievance and appeal rights and protections afforded to them under the law. A robust grievance program also allows health plans to track and trend grievances for the purpose of uncovering systemic problems, thereby providing the opportunity for quality improvement.
The full agreement can be found here: http://wpso.dmhc.ca.gov/enfactions/docs/2990/1559839362040.pdf
If a consumer is experiencing difficulty in accessing care they should file a grievance with their health plan. If they are not satisfied with their health plan’s resolution of their grievance or have been in their plan’s grievance system for 30 days, they should contact the DMHC Help Center for assistance by calling 1-888-466-2219 or at www.HealthHelp.ca.gov. If they are experiencing an imminent or serious threat to their health, they should contact the DMHC Help Center immediately.
