Anthem Blue Cross faces a $1.1 million fine from the California Department of Managed Health Care for two legal breaches causing patient cost escalation. The insurer is penalized $750,000 for wrongly attributing office visits to deductibles affecting 6,500 members and $360,000 for failing to send 363,000 members an explanation of benefits documents. Corrective actions include $9.2 million in reimbursement and policy updates. Anthem aims to prevent future issues alongside the fines, emphasizing compliance with consumer healthcare rights and payment obligations.
Anthem Blue Cross has been imposed with fines totaling $1.1 million by the California Department of Managed Health Care due to their involvement in two legal breaches that allegedly led to elevated expenses for patients.
The regulatory body has levied a $750,000 penalty against the insurer for inaccurately attributing office visits to certain members’ deductibles, causing an impact on over 6,500 individuals spanning the years from 2015 to 2020. Moreover, Anthem Blue Cross is required to settle a $360,000 fine for neglecting to dispatch explanation of benefits (EOB) documents to over 363,000 members in 2019.
The department has communicated that Anthem Blue Cross has consented to undertake a series of remedial measures to rectify these issues. These steps encompass compensating affected members for the expenses they incurred due to office visits not being correctly excluded from their deductibles, amounting to a substantial $9.2 million in disbursements.
DMHC Director Mary Watanabe affirmed, “The enforcement actions initiated by DMHC against Anthem Blue Cross serve as a potent reminder that the Department remains steadfast in upholding the legal framework and safeguarding the healthcare entitlements of consumers.”
Watanabe further elaborated, “These transgressions bore financial ramifications for enrollees, depriving them of both financial clarity and the awareness of their prerogatives to file grievances or avail themselves of an Independent Medical Review through the DMHC Help Center. Anthem Blue Cross has demonstrated its commitment to rectification by agreeing to rectify the affected enrollees’ grievances and enhancing the plan’s policies to preclude any recurrence of such issues.”
According to regulations, healthcare plans are obligated to furnish EOBs to their members, ensuring that they possess comprehensive insights into their personal payment obligations. This facilitates the streamlined tracking of out-of-pocket expenditures over a year while also delineating crucial particulars such as avenues for appeals.
Concurrently with the reimbursement endeavors, Anthem Blue Cross has pledged to enact supplementary measures to prevent the recurrence of these predicaments in the foreseeable future, as per directives issued by DMHC.