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Gianelli & Morris Gianelly & Morris A Law Corporation
  • We Fight Insurance Companies and Win

Anthem Blue Cross in the DMHC Crosshairs… Over and Over Again

Gavel With Medical Stethoscope while doctor using laptop, Concept of medical law and medical crimes.

The Department of Managed Health Care (DMHC) is a California government agency tasked with protecting the rights of consumers to receive the benefits and services their health plans are supposed to provide. When health insurers fail to do their jobs, the DMHC Office of Enforcement is there to hold them accountable for their failings in the hopes they will do better in the future. Yet reality shows insurance companies like Blue Cross of California, aka Anthem Blue Cross, making the same mistakes over and over again. In fact, in just the first quarter of this year (January through March), Anthem has been the subject of 17 enforcement actions totaling $832,500 in penalties. This puts the California health plan well on track to beat 2023 when it got hit with 30 enforcement actions for the entire year. What’s more, the 2024 penalties incurred to-date more than double last year’s total of $359,000.

Read on for a description of the actions Anthem has been called out for by California’s regulators so far this year. If you have been the victim of unfair or bad faith insurance practices in California, by Anthem or any other insurer operating in the state, contact Gianelli & Morris to speak with an experienced and successful California insurance law attorney.

Failure to Resolve Grievances Within the Required 30 days – $62,500

In one instance, an enrollee received emergency ground ambulance services from an out-of-network provider. The plan determined the enrollee had no patient responsibility for the bill yet nevertheless only paid a portion of the bill, leaving the patient with a balance. After calling to dispute the bill and getting no relief, the enrollee initiated a standard grievance. The plan responded by assuring the enrollee they would pay the whole bill, but of course they didn’t do so. Eventually, Anthem paid the remaining balance, over five months later.

DMHC cited Anthem for improperly adjusting the claim, failing to timely pay the claim, and failing to resolve and rectify the grievance within 30 days as required by law. Anthem was penalized $40,000.

Similarly, Anthem was again cited following a pair of grievances initiated following a billing discrepancy, where the provider’s services were processed as in-network, but the benefits were applied as though the provider was out-of-network. Anthem was called out for failing to adequately investigate and resolve the issues raised in the grievances and for providing a response to the enrollee that was neither clear nor concise as required by law. Anthem was fined $22,500 for these failures.

Failure to Establish and Maintain a Grievance System – $30,000

Failing to resolve a grievance within 30 days is bad enough, but twice so far this year Anthem has been dunned for failing to establish and maintain a grievance system for policyholders. In one instance, Anthem improperly denied a pregnant woman’s request for OB/GYN maternity services and then failed to provide an adequate response to the grievance filed by the enrollee. This move cost the insurer $20,000. Anthem was again hit with another $10,000 for failing to adequately investigate and resolve the issues in the enrollee’s grievance regarding an oral appliance to relieve the patient’s obstructive sleep apnea. Although Anthem certified the durable medical equipment as medically necessary, it turned down the provider’s claim for reimbursement as impermissible unbundling since they billed separately for fabricating the device and for fitting and adjustment.

Failure to Provide Reasons for Denial of ER Services – $20,000

A policyholder who had been in an accident woke up with leakage from her ear and nausea, so she went to the ER at an out-of-network hospital, where she was admitted, given a CT scan, and diagnosed with a fractured skull. Anthem denied the claim entirely, saying full hospital admission was “medically unnecessary.” After filing a grievance and receiving no satisfactory response within 30 days, the enrollee filed a complaint with DMHC. An IMR, to which both parties agreed to be bound, found that the ER admission was medically necessary. Anthem was fined $20,000 for improper claim processing.

Failure to Promptly Implement the Decision of an Independent Medical Review Overturning the Plan’s Denial – $690,000

In nine associated cases, Anthem was smacked with a whopping $690,000 in penalties for violating provisions of the California Health and Safety Code which require Insurers to timely reimburse the healthcare provider or enrollee within five working days after receiving an Independent Medical Review (IMR) that overturns the Plan’s initial denial. These cases involved a variety of disputes that required enrollees to seek an IMR, including Anthem denying coverage for behavioral health matters in a residential treatment center. About half of the cases involved Anthem denying this form of care based on its time-worn “medical necessity” excuse.

Is Anthem Denying You Coverage in Bad Faith? Call Gianelli & Morris for Help Today!

Gianelli & Morris is a leading California insurance law firm holding Anthem and other insurers accountable for the harm they have caused by their unreasonable, wrongful, and bad faith insurance practices. DMHC penalties might not always get Anthem’s attention, but a lawsuit that includes punitive damages for bad faith conduct usually will. Call our office in Los Angeles at 213-489-1600 for a free consultation to talk about what happened and find out how we can help.

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