DMHC Fines Anthem $415,000 for Grievance System Violations

(Sacramento) –The California Department of Managed Health Care (DMHC) announced today that it issued a $415,000 fine against Anthem Blue Cross (Anthem) for failing to identify, timely process, and resolve enrollees’ grievances. Anthem also failed to fully and timely provide information to the Department during the investigation of member complaints.

“The DMHC is committed to protecting the health care rights of Californians,” said DMHC Director Shelley Rouillard. “Health plan members have many health care rights, including the right to file a grievance. The grievance process is fundamental to ensuring members receive needed health care services with their health plans.”

The DMHC identified 40 cases involving 83 violations where Anthem deprived members of their grievance and appeal rights. Anthem must provide a detailed report to the DMHC in 90 days analyzing the corrective actions it has taken to fix this pattern of violations. The corrective actions include employee training and increased oversight of the grievance and appeals system.

Health plans’ grievance programs are supposed 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, such as the right to pursue an Independent Medical Review or file a complaint with the DMHC if they are dissatisfied with the health plan’s decision.

A robust grievance program allows health plans to track and trend grievances for the purpose of uncovering systemic problems, thereby providing the opportunity for quality improvement.

In California, health plan members have many health care rights including the right to know why a plan denies a service or treatment, and the right to file a grievance if they disagree. Members also have the right to file a complaint and request an Independent Medical Review from the DMHC.