Not a Very Merry Month of May for Anthem
$140,000 Administrative Penalties Issued by the DMHC
![Not a Very Merry Month of May for Anthem $140,000 Administrative Penalties Issued by the DMHC Blue Cross of California, dba Anthem Blue Cross, is a major for-profit health insurance company operating throughout the state, providing HMO, PPO, and EPO health plans to over 45 million subscribers through Covered California, Medicare, Medi-Cal, and employer-sponsored group plans. With such a large footprint, you might think Anthem would provide a smooth and seamless level of service to its customers, but this is not necessarily the case. Month after month, year after year, Anthem continues to lead the pack of California health plans taken to task for errors in the ways it approves, processes and pays claims. Last month was no exception. Despite being hit with tens of thousands or hundreds of thousands of dollars in fines each month, Anthem continues to be brought before the state for making the same mistakes and denying patients access to the care they need. At Gianelli & Morris in Los Angeles, our law firm takes on Anthem and other California health plans for improper health insurance denials and other failures that violate the law or amount to insurance bad faith. Below, we look at just a couple of recent examples of the ways Anthem has been found to mistreat its policyholders. The DMHC Office of Enforcement The California Department of Managed Health Care (DMHC) is a state regulatory agency that licenses managed health care plans (like HMOs) and protects the health care rights of approximately 25 million Californians. Its primary role is to enforce state laws to ensure health plans maintain adequate provider networks, provide timely access to care, and remain financially stable. One of the primary functions of the DMHC in this regard is consumer assistance and dispute resolution through a complaint process intended to resolve billing issues, claim disputes, and difficulties securing appointments within the timeframes required by law. When an enrollee files a complaint with the DMHC, the Department investigates and contacts the Health Plan with its findings. These complaints are filed only after the enrollee failed to resolve the issue with the Health Plan directly through its own internal grievance process. Even when a complaint is successfully resolved, if the DMHC finds the Health Plan violated California laws and regulations, it is likely to institute an enforcement action and penalize the Health Plan for its failures. So far this year, DMHC has instituted 131 enforcement actions against California Health Plans. Thirty-five of those have been against Anthem. In May alone, 20% of the enforcement actions were brought against Blue Cross of California d.b.a. Anthem Blue Cross, amounting to $140,000 in penalties in one month. ENFORCEMENT MATTER NUMBER: 24-987 On May fifth, DMHC issued an enforcement action with a $40,000 fine against Anthem for violations of California Health and Safety Code 1371.8 and California Code of Regulations 1300.71(d)(1). In this case, Anthem had authorized the enrollee’s infusion medication and related services in December 2023. Relying on that authorization, the enrollee received infusion and related services in February 2024. Anthem received the claim in April and issued an explanation of benefits (EOB) applying insurance benefits to the services but denying coverage for the medication. The EOB stated authorization was required for the medication, falsely implying it had not previously authorized the medication. The enrollee was left responsible for $44,875.83 in medical expenses. The enrollee first filed a grievance with Anthem and received a response two days later stating that coverage was approved, the claim was reprocessed, and a revised EOB should be forthcoming. Two weeks later, the Department of Insurance filed a complaint against Anthem, accusing the plan of delaying payment and requiring the enrollee to delay care while the claim was still pending. Over two weeks later, Anthem responded to the complaint, admitting that the claim had been incorrectly processed and confirming it had been sent for adjustment. Over a week later, Anthem finally issued a revised EOB covering the medication and services in full with no cost share. In its enforcement letter, DMHC cited California law, stating, that “[u]nder Health and Safety Code section 1371.8, a plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization for any reason after the provider renders the health care service in good faith and pursuant to the authorization.” DMHC therefore found that Anthem “improperly denied, adjusted, or contested the enrollee’s claims in violation of California Code of Regulations, section 1300.71, subdivision (d)(1).” ENFORCEMENT MATTER NUMBER: 24-177 On the same day as the prior matter, DMHC issued Enforcement Matter 24-177, this time with a $50,000 administrative penalty. This matter again addressed California Code of Regulations 1300.71(d)(1), as well as a violation of Health and Safety Code 1368 and 1300.68(a)(1), related to the failure to adequately consider an enrollee’s grievance. This case began when the enrollee received a series of in-network tests in 2023. The related claims were improperly processed under the wrong section of Anthem’s evidence of coverage (EOC), resulting in excessive copayments charged to the subscriber. The policyholder filed a grievance, but Anthem upheld its decisions, leading to a complaint from the DMHC. Only at this stage did Anthem admit the claims were improperly processed and agree to reprocess the claims. Anthem’s errors here included improperly adjusting a claim and then failing to thoroughly evaluate EOC provisions during the grievance stage. These mistakes violated key provisions of California law, including Health and Safety Code 1368(a)(1) “Failure to establish and maintain a department-approved enrollee grievance system” and California Code of Regulations 1300.71(d)(1) “Failure to provide an accurate and clear written explanation of the specific reasons for denying, adjusting, or contesting a claim” within required timeframes. Contact the California Insurance Lawyers at Gianelli & Morris A third enforcement action was also issued against Anthem, bringing the total penalties for the month to $140,000. Penalties of this size are not new to Anthem and continue to be issued month after month, often for the same reasons. A different kind of legal action is sometimes needed to make Anthem take responsibility for its wrongful conduct and fully compensate policyholders for all the ways they have been damaged beyond an unpaid claim or delayed access to care. In certain cases, punitive damages may be warranted as well. Gianelli & Morris takes on cases against Anthem for wrongful denials of health care coverage. These cases often include a component alleging bad faith insurance practices, giving rise to a punitive damages claim along with compensatory damages. If you have been harmed by unlawful insurance practices in California by Anthem or another insurance company, contact Gianelli & Morris for a free consultation to review your situation and find out how we can help.](https://www.gmlawyers.com/wp-content/uploads/2026/07/representation-of-criminal-penalties-with-sack-labeled-penalty-beside-gavel-on-justice-scales-200x200.webp "Not a Very Merry Month of May for Anthem $140,000 Administrative Penalties Issued by the DMHC Blue Cross of California, dba Anthem Blue Cross, is a major for-profit health insurance company operating throughout the state, providing HMO, PPO, and EPO health plans to over 45 million subscribers through Covered California, Medicare, Medi-Cal, and employer-sponsored group plans. With such a large footprint, you might think Anthem would provide a smooth and seamless level of service to its customers, but this is not necessarily the case. Month after month, year after year, Anthem continues to lead the pack of California health plans taken to task for errors in the ways it approves, processes and pays claims. Last month was no exception. Despite being hit with tens of thousands or hundreds of thousands of dollars in fines each month, Anthem continues to be brought before the state for making the same mistakes and denying patients access to the care they need. At Gianelli & Morris in Los Angeles, our law firm takes on Anthem and other California health plans for improper health insurance denials and other failures that violate the law or amount to insurance bad faith. Below, we look at just a couple of recent examples of the ways Anthem has been found to mistreat its policyholders. The DMHC Office of Enforcement The California Department of Managed Health Care (DMHC) is a state regulatory agency that licenses managed health care plans (like HMOs) and protects the health care rights of approximately 25 million Californians. Its primary role is to enforce state laws to ensure health plans maintain adequate provider networks, provide timely access to care, and remain financially stable. One of the primary functions of the DMHC in this regard is consumer assistance and dispute resolution through a complaint process intended to resolve billing issues, claim disputes, and difficulties securing appointments within the timeframes required by law. When an enrollee files a complaint with the DMHC, the Department investigates and contacts the Health Plan with its findings. These complaints are filed only after the enrollee failed to resolve the issue with the Health Plan directly through its own internal grievance process. Even when a complaint is successfully resolved, if the DMHC finds the Health Plan violated California laws and regulations, it is likely to institute an enforcement action and penalize the Health Plan for its failures. So far this year, DMHC has instituted 131 enforcement actions against California Health Plans. Thirty-five of those have been against Anthem. In May alone, 20% of the enforcement actions were brought against Blue Cross of California d.b.a. Anthem Blue Cross, amounting to $140,000 in penalties in one month. ENFORCEMENT MATTER NUMBER: 24-987 On May fifth, DMHC issued an enforcement action with a $40,000 fine against Anthem for violations of California Health and Safety Code 1371.8 and California Code of Regulations 1300.71(d)(1). In this case, Anthem had authorized the enrollee’s infusion medication and related services in December 2023. Relying on that authorization, the enrollee received infusion and related services in February 2024. Anthem received the claim in April and issued an explanation of benefits (EOB) applying insurance benefits to the services but denying coverage for the medication. The EOB stated authorization was required for the medication, falsely implying it had not previously authorized the medication. The enrollee was left responsible for $44,875.83 in medical expenses. The enrollee first filed a grievance with Anthem and received a response two days later stating that coverage was approved, the claim was reprocessed, and a revised EOB should be forthcoming. Two weeks later, the Department of Insurance filed a complaint against Anthem, accusing the plan of delaying payment and requiring the enrollee to delay care while the claim was still pending. Over two weeks later, Anthem responded to the complaint, admitting that the claim had been incorrectly processed and confirming it had been sent for adjustment. Over a week later, Anthem finally issued a revised EOB covering the medication and services in full with no cost share. In its enforcement letter, DMHC cited California law, stating, that “[u]nder Health and Safety Code section 1371.8, a plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization for any reason after the provider renders the health care service in good faith and pursuant to the authorization.” DMHC therefore found that Anthem “improperly denied, adjusted, or contested the enrollee’s claims in violation of California Code of Regulations, section 1300.71, subdivision (d)(1).” ENFORCEMENT MATTER NUMBER: 24-177 On the same day as the prior matter, DMHC issued Enforcement Matter 24-177, this time with a $50,000 administrative penalty. This matter again addressed California Code of Regulations 1300.71(d)(1), as well as a violation of Health and Safety Code 1368 and 1300.68(a)(1), related to the failure to adequately consider an enrollee’s grievance. This case began when the enrollee received a series of in-network tests in 2023. The related claims were improperly processed under the wrong section of Anthem’s evidence of coverage (EOC), resulting in excessive copayments charged to the subscriber. The policyholder filed a grievance, but Anthem upheld its decisions, leading to a complaint from the DMHC. Only at this stage did Anthem admit the claims were improperly processed and agree to reprocess the claims. Anthem’s errors here included improperly adjusting a claim and then failing to thoroughly evaluate EOC provisions during the grievance stage. These mistakes violated key provisions of California law, including Health and Safety Code 1368(a)(1) “Failure to establish and maintain a department-approved enrollee grievance system” and California Code of Regulations 1300.71(d)(1) “Failure to provide an accurate and clear written explanation of the specific reasons for denying, adjusting, or contesting a claim” within required timeframes. Contact the California Insurance Lawyers at Gianelli & Morris A third enforcement action was also issued against Anthem, bringing the total penalties for the month to $140,000. Penalties of this size are not new to Anthem and continue to be issued month after month, often for the same reasons. A different kind of legal action is sometimes needed to make Anthem take responsibility for its wrongful conduct and fully compensate policyholders for all the ways they have been damaged beyond an unpaid claim or delayed access to care. In certain cases, punitive damages may be warranted as well. Gianelli & Morris takes on cases against Anthem for wrongful denials of health care coverage. These cases often include a component alleging bad faith insurance practices, giving rise to a punitive damages claim along with compensatory damages. If you have been harmed by unlawful insurance practices in California by Anthem or another insurance company, contact Gianelli & Morris for a free consultation to review your situation and find out how we can help.")
Blue Cross of California, dba Anthem Blue Cross, is a major for-profit health insurance company operating throughout the state, providing HMO, PPO, and EPO health plans to over 45 million subscribers through Covered California, Medicare, Medi-Cal, and employer-sponsored group plans. With such a large footprint, you might think Anthem would provide a smooth and seamless level of service to its customers, but this is not necessarily the case. Month after month, year after year, Anthem continues to lead the pack of California health plans taken to task for errors in the ways it approves, processes and pays claims. Last month was no exception.
Despite being hit with tens of thousands or hundreds of thousands of dollars in fines each month, Anthem continues to be brought before the state for making the same mistakes and denying patients access to the care they need. At Gianelli & Morris in Los Angeles, our law firm takes on Anthem and other California health plans for improper health insurance denials and other failures that violate the law or amount to insurance bad faith. Below, we look at just a couple of recent examples of the ways Anthem has been found to mistreat its policyholders.
The DMHC Office of Enforcement
The California Department of Managed Health Care (DMHC) is a state regulatory agency that licenses managed health care plans (like HMOs) and protects the health care rights of approximately 25 million Californians. Its primary role is to enforce state laws to ensure health plans maintain adequate provider networks, provide timely access to care, and remain financially stable. One of the primary functions of the DMHC in this regard is consumer assistance and dispute resolution through a complaint process intended to resolve billing issues, claim disputes, and difficulties securing appointments within the timeframes required by law.
When an enrollee files a complaint with the DMHC, the Department investigates and contacts the Health Plan with its findings. These complaints are filed only after the enrollee failed to resolve the issue with the Health Plan directly through its own internal grievance process. Even when a complaint is successfully resolved, if the DMHC finds the Health Plan violated California laws and regulations, it is likely to institute an enforcement action and penalize the Health Plan for its failures.
So far this year, DMHC has instituted 131 enforcement actions against California Health Plans. Thirty-five of those have been against Anthem. In May alone, 20% of the enforcement actions were brought against Blue Cross of California d.b.a. Anthem Blue Cross, amounting to $140,000 in penalties in one month.
ENFORCEMENT MATTER NUMBER: 24-987
On May fifth, DMHC issued an enforcement action with a $40,000 fine against Anthem for violations of California Health and Safety Code 1371.8 and California Code of Regulations 1300.71(d)(1). In this case, Anthem had authorized the enrollee’s infusion medication and related services in December 2023. Relying on that authorization, the enrollee received infusion and related services in February 2024. Anthem received the claim in April and issued an explanation of benefits (EOB) applying insurance benefits to the services but denying coverage for the medication. The EOB stated authorization was required for the medication, falsely implying it had not previously authorized the medication. The enrollee was left responsible for $44,875.83 in medical expenses.
The enrollee first filed a grievance with Anthem and received a response two days later stating that coverage was approved, the claim was reprocessed, and a revised EOB should be forthcoming. Two weeks later, the Department of Insurance filed a complaint against Anthem, accusing the plan of delaying payment and requiring the enrollee to delay care while the claim was still pending. Over two weeks later, Anthem responded to the complaint, admitting that the claim had been incorrectly processed and confirming it had been sent for adjustment. Over a week later, Anthem finally issued a revised EOB covering the medication and services in full with no cost share.
In its enforcement letter, DMHC cited California law, stating, that “[u]nder Health and Safety Code section 1371.8, a plan that authorizes a specific type of treatment by a provider shall not rescind or modify this authorization for any reason after the provider renders the health care service in good faith and pursuant to the authorization.” DMHC therefore found that Anthem “improperly denied, adjusted, or contested the enrollee’s claims in violation of California Code of Regulations, section 1300.71, subdivision (d)(1).”
ENFORCEMENT MATTER NUMBER: 24-177
On the same day as the prior matter, DMHC issued Enforcement Matter 24-177, this time with a $50,000 administrative penalty. This matter again addressed California Code of Regulations 1300.71(d)(1), as well as a violation of Health and Safety Code 1368 and 1300.68(a)(1), related to the failure to adequately consider an enrollee’s grievance.
This case began when the enrollee received a series of in-network tests in 2023. The related claims were improperly processed under the wrong section of Anthem’s evidence of coverage (EOC), resulting in excessive copayments charged to the subscriber. The policyholder filed a grievance, but Anthem upheld its decisions, leading to a complaint from the DMHC. Only at this stage did Anthem admit the claims were improperly processed and agree to reprocess the claims.
Anthem’s errors here included improperly adjusting a claim and then failing to thoroughly evaluate EOC provisions during the grievance stage. These mistakes violated key provisions of California law, including Health and Safety Code 1368(a)(1) “Failure to establish and maintain a department-approved enrollee grievance system” and California Code of Regulations 1300.71(d)(1) “Failure to provide an accurate and clear written explanation of the specific reasons for denying, adjusting, or contesting a claim” within required timeframes.
Contact the California Insurance Lawyers at Gianelli & Morris
A third enforcement action was also issued against Anthem, bringing the total penalties for the month to $140,000. Penalties of this size are not new to Anthem and continue to be issued month after month, often for the same reasons. A different kind of legal action is sometimes needed to make Anthem take responsibility for its wrongful conduct and fully compensate policyholders for all the ways they have been damaged beyond an unpaid claim or delayed access to care. In certain cases, punitive damages may be warranted as well.
Gianelli & Morris takes on cases against Anthem for wrongful denials of health care coverage. These cases often include a component alleging bad faith insurance practices, giving rise to a punitive damages claim along with compensatory damages. If you have been harmed by unlawful insurance practices in California by Anthem or another insurance company, contact Gianelli & Morris for a free consultation to review your situation and find out how we can help.
