SACRAMENTO, Calif. – The Department of Managed Health Care (DMHC) announced that they have taken enforcement actions against Anthem Blue Cross of California, levying a fine of $15 million against Anthem Blue Cross due to ongoing issues with how the health plan handles member complaints.
The DMHC says that Anthem Blue Cross has faced longstanding deficiencies in processing grievances and appeals.
To address these issues, Anthem Blue Cross will collaborate with an independent auditor for up to four years. This partnership aims to ensure that member grievances are handled consistently and correctly.
“This enforcement action is the result of a longstanding and unacceptable pattern by Anthem Blue Cross of failing to appropriately identify, timely process or resolve member grievances,” said DMHC Director Mary Watanabe. “Despite several prior enforcement actions and survey findings by the DMHC, Anthem Blue Cross has repeatedly not resolved the identified failures with its member grievance system for more than 15 years,” continued Watanabe.
According to Watanabe, Anthem Blue Cross must work with an independent auditor to improve their grievance system to protect members’ rights and comply with the law.
The grievance and appeals process is crucial for protecting health plan members and ensuring they receive necessary medical care. California law mandates that health plans have a system in place to review and resolve complaints promptly and appropriately.
Over the past decade and a half, the DMHC has imposed several fines on Anthem Blue Cross for similar issues.
In December 2024, Anthem Blue Cross was fined $3.5 million for sending late grievance acknowledgment letters to members. In November 2024, a $500,000 fine was handed down to Anthem Blue Cross after a member’s cancer treatment was delayed due to grievance handling failures.
Previous fines the DMHC has issued against Anthem Blue Cross include $2.8 million in June 2019 and $2.5 million in November 2009 for similar deficiencies.
Despite past corrective actions, the DMHC’s latest audit revealed repeat deficiencies in Anthem Blue Cross’s grievance system. The audit found that the health plan failed to properly identify grievances in nearly half of the reviewed cases and did not adequately address exempt grievances in 65% of cases.
The DMHC encourages health plan members with complaints about denied, delayed, or modified health care services to file a grievance with their health plan. If unsatisfied with the response or if the health plan takes more than 30 days to respond, members can contact the DMHC Help Center.
For urgent issues, immediate contact with the DMHC Help Center is advised. Members can file complaints or request an Independent Medical Review through the DMHC website or by calling 1-888-466-2219.