Dear Substance Use Treatment Provider and Other Companies in the Industry:
The following article is a cautionary tale about being organized in how an industry deals with insurers. While Anthem was fined for not addressing client grievances in a timely manner by the Department of Managed Health Care, the lesson is what drove DMHC to act was the fact that subscribers and providers filed grievances. As you know, ATAC has asked your organization to file grievances, now you can see the result of those organizations within our industry that did, as well as of those other providers in other parts of healthcare that were experiencing the same problems. Did you file a complaint with DMHC in 2016 when ATAC requested you to complain?
While ATAC applauds the actions of the Department of Managed Health Care, shouldn't the fact that 70% of denials are eventually overturned be considered an unfair payment pattern as defined by the Health and Safety Code 1371.37? Aren't the denials simply a payment delay tactic?
ATAC will be pursuing further action by the Department of Health Care to ensure that Anthem is held fully accountable for all violations of the Health and Safety Code with respect to their actions.
Please read the entire article:
https://www.washingtonpost.com/national/health-science/california-fines-anthem-5-million-for-failing-to-address-consumer-grievances/2017/11/15/7744cd34-ca52-11e7-b506-8a10ed11ecf5_story.html?utm_term=.e5051a6eda05
For those who want to know all the details, here is the actual case:
http://wpso.dmhc.ca.gov/enfactions/docs/2990/1510765385688.pdf
What do you have to complain about today? Underpayments, lack of timely response to contested claims, or ever-changing coding requirements? You must complain to call attention to issues!
Strength in Numbers,
ATAC Board of Directors
|
Blue Cross of California (d.b.a. : Anthem Blue Cross)
|
|
Org. Type: Health Plan |
| Document(s) |
Action Date |
Penalty |
|
|
|
11/15/2017
|
$5,000,000.00
|
|
|
|
Violation #
| 1300.68(a)(1) |
Failure to adequately consider an enrollee's grievance. |
| 1300.68(g) |
Failure to provide the Department with requested information within 5 days |
| 1300.68(g)(1) |
Failure to provide the Department with a written response to the issues in a grievance |
| 1300.68(g)(2) |
Failure to provide the Department with a copy of the Plan's original response to enrollee regarding the grievance |
| 1300.68(h) |
Enrollee may seek direct assistance from the Department for grievances involving imminent or serious threats to health, or if the Department determines that an expedited review is warranted |
| 1368(a)(4)(A) |
Failure to provide written acknowledgment of receipt of grievance within 5 calendar days with the date of receipt and the name, address and telephone number of the plan representative who may be contacted about the grievance. |
| 1368(a)(4)(A)(ii) |
Failure to provide written acknowledgment within five calendar days of receipt of a grievance, advising the date of receipt. |
| 1368(a)(4)(B)(i) |
Failure to maintain a log, or a compliant log, of grievances exempt from Health and Safety Code section 1368, subdivisions (a)(4)(A) and (a)(5); and/or misclassification of standard grievances as exempt grievances. |
| 1368(a)(5) |
Failure to provide clear and concise explanation of Plan's response to enrollee's grievance |
| 1368.01(a) |
Failure to resolve enrollee grievance within 30 days |
| 1368.01(b) |
Failure to notify parties of grievance disposition involving a serious health threat within 3 days |
| 1368.02(b) |
Failure to provide Department's toll-free telephone number, TDD line, Internet Web site address, the plan's telephone number, and specified statement regarding grievances on Plan documents, written notices to enrollees, and responses to grievances. |
| 1368.04(b)(1) |
Repeated failures to promptly and reasonable investigate and resolve grievances |
| 1368.04(b)(2) |
Repeated failures to promptly and reasonably resolve grievances when obligation is reasonably clear |
| 1386(b)(7) |
Plan has engaged in conduct that constitutes fraud or dishonest dealing or unfair competition, as defined by Section of 17200 of the B & P Code. |
|
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