California fines Anthem over unresolved member complaints

California regulators hit health insurer Anthem with a $5 million fine for repeatedly failing to address members’ complaints in a timely manner.

The California Department of Managed Health Care on Nov. 15 criticized Anthem for its ongoing failure to recognize and resolve members’ grievances, pointing to 245 violations between 2013 and 2016 identified during an investigation.

Anthem’s “defective” grievance system creates frustration and stress for patients, and could potentially harm patients’ health if care is delayed, the department said in its complaint. Including the latest fine, the department has fined Anthem nearly $12 million for grievance violations since 2002.

Anthem said in a statement that it “strongly disagrees with the DMHC’s findings and the assertion that these findings are systemic and ongoing. Unfortunately the DMHC has not fulfilled its obligations to clarify the regulatory standards and definitions being applied in the audits, despite multiple requests from Anthem to do so.”

The insurer said it has already taken steps to address issues identified by the regulators.

In one example regulators provided, an Anthem plan member was diagnosed with a serious condition, and Anthem pre-authorized surgery and reconstruction to treat the patient. Later, Anthem denied the claim when it was submitted by the provider. The patient, provider, broker and the patient’s spouse called Anthem 22 times, but the insurer didn’t resolve the complaint, regulators said.

Anthem paid the claim only after the patient sought help from the DMHC more than a year and a half after the treatment. Under California law, health plans are required to have grievance systems to address and resolve members’ complaints within 30 days.