Anthem Blue Cross will pay $2.8 million to the state of California and invest $8.4 million to improve how it logs consumer calls as part of a settlement with the Department of Managed Health Care over its allegations that the insurer was failing to identify, process or resolve consumer complaints, the department announced Thursday.
“This is not a common amount for a fine,” said DMHC Director Shelley Rouillard, in a telephone interview with The Bee. “This is a very large fine for us, and it’s appropriate in this case because, for many years, Anthem has improperly denied consumers their right to information about how they can appeal decisions that Anthem has made and how Anthem has handled what we call grievances.”
The settlement closes out Anthem’s appeal of a $5 million fine that the DMHC levied in 2017, saying there was a systemic pattern of failure within the grievance process in Anthem’s managed-care plans. Rouillard said attorneys and analysts in the department’s help center have assisted consumers with resolving roughly 175 cases.
Anthem Blue Cross spokesperson Michael Bowman said that company leaders are pleased to have worked along with DMHC to resolve this matter.
“Anthem is making significant changes in our grievance and appeals process, as well as investments in system improvements to help ensure we are simplifying the health care experience for consumers,” Bowman stated in an email to The Bee.
Rouillard said that Anthem is not the only plan that has grievance system problems. They all do, she said, but Anthem’s failures have been particularly longstanding, and they have the highest rate of complaints to the help center, compared with the other plans.
When an enrollee of Anthem has called up to complain about something, Rouillard said, customer service representatives have not properly classified the call as grievances, or expressions of dissatisfaction.
“The system that Anthem had basically defaulted calls that came in from consumers to what they would call inquiries,” she said. “That doesn’t trigger the whole notification process that a grievance would. So the customer service agents had to figure out: Is this call just an inquiry, or is it really a grievance? Is it a complaint?”
To remedy this, Rouillard said, Anthem will change the default for all consumer contacts to grievances. That will ensure that customers get the notification of their rights for appealing their health plan’s decision, Rouillard said, and the plan must resolve consumer grievances within 30 days.
If it turns out that consumers just need an insurance card or want to change who’s covered, Anthem can then change the designation for those calls to inquiries. As part of the settlement, Anthem also agreed to file regular reports on its progress to DMHC over the next two years, Rouillard said, and her team in the help center will continue to monitor the level of complaints that the insurers’ plans receive. The DMHC also does an audit of each insurer’s managed-care plans every three years.
“The consumers that came to our help center got their issues resolved because they contacted us, and the attorneys and analysts who work at the help center got in touch with the plan to try to solve the individual consumer issues,” Rouillard said. “By having all of these consumers contact us, we’re able to identify systemic issues with the plans and then prosecute (Anthem) for their failure to follow the law. If we hadn’t gotten all of these cases, we wouldn’t have had as strong a case against Anthem.”
Consumers can reach the DMHC Help Center for assistance by calling 888-466-2219 or filling out a form at www.healthhelp.ca.gov.