Anthem hit with $5M fine over allegations it didn't promptly resolve complaints

The California Department of Managed Health Care fined Anthem subsidiary Blue Cross of California $5 million, accusing the insurer of "systemic" grievance resolution violations.

"Anthem Blue Cross has demonstrated a pattern and practice of failing to identify, timely process and resolve enrollees' grievances. Anthem Blue Cross has also failed to fully and timely provide information to the Department during the investigation of member complaints," DMHC claimed.

During an investigation of consumer complaints dated 2013 through 2016, DMHC uncovered 245 grievance system violations. The department highlighted one accusation concerning an Anthem member who received prior authorization to undergo surgery. When the member's claim was denied, the enrollee and his or her representatives called Anthem 22 times. However, no resolution surfaced, the department alleged.

In a statement to Becker's Hospital Review, Anthem spokesperson Suzanne Zagata-Meraz said, "Anthem strongly disagrees with the DMHC's findings and the assertion that these findings are systemic and ongoing. Unfortunately the DMHC has not fulfilled its obligations to clarify the regulatory standards and definitions being applied in the audits, despite multiple requests from Anthem to do so."

Ms. Zagata-Meraz added the payer is "taking the necessary actions to address issues that were identified and have made changes to our appeals and grievances process while enhancing our systems."

Including the $5 million fine, Anthem faces $11.66 million in fines for grievance violations since 2002, DMHC said.

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