DMHC Processes over 1,500 Member Complaints Against Anthem in 2023

In California, the Department of Managed Health Care (DMHC) regulates health insurers operating in the state, making sure they comply with state and federal laws and holding them accountable when they don’t. A good portion of the agency’s oversight begins with complaints from policyholders regarding the way their health plan is treating them. When a member has a problem that they can’t resolve through their insurer’s grievance process, the next logical step for many is to turn to the DMHC. The agency’s Help Center fields customer complaints and can often resolve them by working with the health plan, showing the company where it erred, and getting it to reverse its decision or right the wrong it committed.

Other times, the DMHC is forced to take enforcement actions and assess financial penalties against insurance companies for legal violations. In 2023 (the most recent year for which data is available due to the large number of complaints and actions taken annually), the agency assessed well over $50 million in fines against health plans like Anthem, Aetna, HealthNet and others doing business in California. Failure to pay claims, deceptive tactics during enrollment, and violations of member confidentiality are a few of the leading reasons health plans are routinely fined by the DMHC. Failure to follow its grievance policy or even maintain an adequate grievance procedure in the first place is another common failure among insurance companies.

Below, we look at the number and type of complaints lodged against Anthem by its members in 2023. If you feel your insurance company is treating you unfairly and violating its duty of good faith that it owes to you, contact Gianelli & Morris in Los Angeles to speak with a skilled and experienced California insurance bad faith lawyer.

Complaints Against Anthem Top 1,500 in 2023

DMHC recently released 2023 data on member complaints against the insurance companies under its purview. The agency resolved 1,559 complaints lodged against Anthem that year, accounting for 19.1% of all complaints against health plans with an enrollment of over 400,000. Blue Shield of California, an independent member of the Blue Shield Association, actually led the pack with 2,470 complaints resolved against it, which amounted to 30.2% of all large-insurer complaints. Only 111 (1.4%) complaints were resolved against Anthem’s Medi-Cal subsidiary Blue Cross Partnership Plan, which has a lower enrollment compared to Anthem and Blue Shield. These plans together made up over half of all complaints resolved against the largest insurers in the state.

So what was the basis for the complaints against Anthem? Here is a breakout of the 1,559 complaints by category, ranked from most complaints to least (individual complaints can include multiple categories, so these numbers add up to 2,347 instead of 1,559):

• Claims/Financial – 976 (41.49%)
• Benefits/Coverage – 543 (23.14%)
• Health Plan Customer Service – 379 (16.15%)
• Provider Customer Service – 153 (6.52%)
• Access to Care – 147 (6.26%)
• Enrollment – 133 (5.67%)
• Coordination of Benefits – 16 (0.68%)

The most complaints lodged against Anthem fell in the Claims/Financial category. An example of a complaint in this area provided by DMHC concerned an incorrectly processed complaint that left the plan member stuck with a bill of over $1,200 for a routine, preventive colonoscopy performed by an in-network provider. After unsuccessfully going through the plan’s grievance process, the patient filed a complaint with the DMHC. The agency pointed out to the health plan that California law mandates the provision of preventive colorectal cancer screening tests with no cost share for the enrollee. The plan worked with the provider to adjust the bill so the patient was no longer financially responsible for the crippling bill.

An illustrative example of a Benefits/Coverage complaint centered around a patient whose hospital stay following spinal surgery was denied as being out-of-network, despite the patient previously being told the stay would be covered. Audio recordings between the plan member and the insurer revealed that the insurance company had indeed told the patient his hospital stay would be covered. The carrier reprocessed the claim, which had amounted to nearly $66,000.

Generally speaking, Timely Access to Care means you get an appointment when you need one. Specifically, you are entitled to see a primary care physician within 10 days or specialty care within 15 days if the matter is not urgent. In urgent situations, you are entitled to an appointment within 48 hours if no prior authorization is required or within 96 hours in cases where the insurance company requires preauthorization. The appointment should be within 15 miles or 30 minutes from where the member lives or works. Additionally, health plans are required by California law to provide 24/7 telephone access and provide an interpreter when needed. DMHC resolved 147 complaints against Anthem in 2023 by members alleging the company failed to provide timely access to care.

Your Insurance Company Might Fail You, but California Law Gives You Options. Call Gianelli & Morris Today.

If your insurance company had turned down your request for treatment or denied coverage of a medical procedure, it may have made the wrong decision. They might even have been acting in bad faith. Talk to a dedicated California insurance law attorney at Gianelli & Morris to see if you are entitled to compensation for the harm done to you by bad faith insurance conduct, including punitive damages to hold them accountable. Contact us today for a free consultation.