DMHC Releases 2023 Data of Independent Medical Reviews Concerning Anthem, Blue Cross, Blue Shield and Others
The Department of Managed Health Care (DMHC) is the state agency in charge of regulating health insurance plans in California, with the goal of ensuring compliance with state and federal laws. Policyholders can file consumer complaints with the DMHC when they feel they are not being treated properly by their insurer. In the case of an insurance claim denial, policyholders can request an independent medical review (IMR) through the DMHC, after which the agency can uphold or overturn the claim denial.
Given the high volume of IMR requests made to the DMHC every year, it takes time for the agency to publicly report on its activities. Recently, the DMHC released data for 2023, showing the number of IMRs it processed for that year and how they turned out. See below for a summary of this latest data as it pertains to Anthem and other Blue Cross Blue Shield entities in California. If your insurance company is not treating you fairly or is not handling your claim in good faith, you can seek an IMR with the DMHC or contact Gianelli & Morris to explore your options with a team of dedicated California insurance bad faith attorneys.
Anthem Blue Cross
In 2023, DMHC resolved 863 Independent Medical Reviews concerning Blue Cross of California, aka Anthem Blue Cross. The vast majority of IMR requests surrounded Anthem denials based on “medical necessity.” In other words, Anthem denied a claim or request for services by alleging that the proposed treatment or procedure was not “medically necessary,” which is a standard coverage requirement imposed by insurance companies. However, as we know from decades of fighting wrongful insurance claim denials, insurance companies like Anthem often say a service is not medically necessary with little support to back up their claim.
Of the 863 IMRs involving Anthem in 2023, 688 of them centered around a medical necessity denial. After review, only 138 (20.1%) of those denials were upheld. A whopping 472 (68.6%) of Anthem decisions were overturned by DMHC after the IMR, and 78 (11.3%) were reversed by the plan, meaning that Anthem changed its stance before the DMHC made its decision and decided to authorize the requested service.
While denials based on an alleged lack of medical necessity are most common, many other denials occur when an insurance company alleges the requested procedure, surgery, or medication is “experimental” or “investigational.” Insurers often apply this ground to deny newer and more expensive treatments, even when the proposed service has been published in peer-reviewed journals and routinely performed at major medical centers.
True to form, Experimental/Investigational was the second-leading basis for IMRs involving Anthem in 2023. Out of 173 IMRs on this ground, 85 (49.1%) denials were overturned after review. Another 11 (6.4%) were reversed by the plan, leaving well under half upheld by the DMHC.
Blue Cross of California Partnership, Inc.
Although the numbers were smaller, the situation was similar for Blue Cross of California Partnership, Inc., which is a subsidiary of Anthem providing managed care services to Medi-Cal beneficiaries in California. Here, out of 25 IMRs resolved in 2023, 23 of them involved a Medical Necessity denial. Eight were overturned and eight reversed by the plan, leaving only 30.4% upheld by the DMHC after review. The agency also fielded two IMRs regarding Experimental/Investigational denials, upholding one and overturning the other, giving this Anthem subsidiary its best showing with a dismal 50% success rate.
California Physicians’ Service (Blue Shield of California)
Not to be confused with Blue Cross of California, which goes by the name of Anthem Blue Cross and is a licensee of the Blue Cross Blue Shield Association, Blue Shield of California is an independent licensee of the Blue Cross Blue Shield Association that operates as a separate entity within the larger BCBS system. Like Anthem, Blue Shield of California is a massive health insurer that, not surprisingly, was the subject of a large number of IMRs in 2023. DMHC overturned 357 (55.3%) out of 645 claim denials based on Medical Necessity and upheld only 124 (19.2%). The remaining 164 (25.54%) denials were reversed by the plan before the IMR process could be completed.
Insurance Claim Denied in California? Contact Gianelli & Morris in Los Angeles for a Free Consultation.
If your request for coverage is denied by your insurer, your first recourse is generally to the insurance company’s internal grievance process. An IMR might be a helpful next step, but it is not required, and given the volume of IMR requests the DMHC fields every year, it might not be the swiftest route to medical coverage. To review your situation and explore your options with an experienced California insurance law attorney, contact Gianelli & Morris in Los Angeles for a free consultation.
