In another rebuke by state health officials, Anthem Blue Cross has been fined $415,000 for failing to promptly or completely answer consumer complaints, according to the California Department of Managed Health Care.
All of California’s health plans have lapses in addressing consumer grievances, but “for Anthem, it’s an ongoing systemic problem,” said department Director Shelley Rouillard. “Anthem has the largest fines. They have the largest pattern of violations of enrollee grievances.”
Anthem was cited in 40 cases involving 83 violations, such as not addressing consumer complaints within 30 days as state law requires or failing to provide state investigators with adequate information.
“Anthem Blue Cross is committed to providing access to high quality and affordable health care,” said spokesman Darrel Ng in an email. “In order to resolve the issues identified by the Department of Managed Health Care, Anthem has provided additional training to its staff and implemented a new tracking system to reduce delays with the grievance and appeals system.”
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In the past six years, Anthem has been cited for various grievance violations. The high-water mark was in 2011, when it was fined $800,500 involving a total of 219 cases. In that instance, the volume was high because of a case backlog from prior years.
Along with this year’s fine, Anthem has 90 days to submit a report on its corrective actions.
The fines come as Anthem Inc. and Cigna Corp. are pursuing a $56 billion merger that has drawn criticism from consumer groups. State Insurance Commissioner Dave Jones, who has said the merger would create the nation’s biggest health insurer, is reviewing testimony from a March 29 public hearing on the proposal. Spokeswoman Nancy Kincaid said Wednesday that Jones has no timetable for issuing a decision on the proposed merger.
Under California’s health care consumer protection laws, patients enjoy rights including prompt appointments, second medical opinions and explanations when treatment is denied. Those who are unhappy with how they are treated are advised to first contact their health plan’s consumer department. If not satisfied by the health plan’s response, they can file a grievance with the state’s managed care help center, either online at HealthHelp.ca.gov or by calling 888-466-2219.
GOT A HEALTH CARE COMPLAINT?
First, contact your health care plan or physician’s office, either by phone, email or letter. Ask for the customer service department. If the issue isn’t resolved, you can file a complaint with the state Department of Managed Health Care. Call 888-466-2219 or file an online complaint at HealthHelp.ca.gov. Complaint forms are available in 13 languages.
If you need help filing a complaint, contact the Health Consumer Alliance, a group of free legal services centers covering all of California’s 58 counties. To find the nearest center, call 888-804-3536.
In addition, if you’re denied a specific medical treatment or procedure, you can request an Independent Medical Review (IMR) from the Department of Managed Health Care. Independent physicians will review your case within seven to 30 days. (IMRs are not available for Medicare or workers’ compensation issues.)
For help with Medicare problems, contact the Health Insurance Counseling and Advocacy Program (HICAP) at 800-434-0222.