California Department of Managed HealthCare
DMHC Fines Blue Shield and Anthem for Inaccurate Provider Directories
Enrollees Reimbursed Nearly $40 Million in Costs, More Expected
(Sacramento) – The California Department of Managed Health Care (DMHC) announced today that it issued a $350,000 fine against Blue Shield of California (Blue Shield) and a $250,000 fine against Anthem Blue Cross (Anthem) for inaccurate provider directories.
“An important element of access is ensuring enrollees have accurate provider directories,” said DMHC Director Shelley Rouillard. “The DMHC has taken enforcement action and fined Blue Shield and Anthem due to unacceptable inaccuracies in their directories. These inaccuracies limited enrollee access to care that resulted in an unacceptable consumer experience and must be fixed.”
Both plans must improve the accuracy of their provider directories and reimburse enrollees who may have been negatively impacted by inaccuracies in provider directories. Blue Shield has already reimbursed more than $38 million to enrollees who incurred out-of-network costs. Both Blue Shield and Anthem will report to the Department the final number of enrollees reimbursed and the total amount reimbursed.
Enrollees that have questions or believe they should receive reimbursement by Blue Shield or Anthem should call the number on the back of their plan member card.
Background:
Between January and May 2014, the DMHC Help Center received numerous complaints from Blue Shield and Anthem individual market enrollees who could not find a primary care physician in their area or alleged that they had been misled by inaccurate health plan provider network directories. In response to these complaints, the DMHC conducted informal surveys of the plans’ individual provider networks. The results of these informal surveys led the DMHC to initiate non-routine surveys of these plans’ individual market provider networks.
The survey found:
• For Blue Shield, 18.2 percent of the physicians listed in Blue Shield’s provider directory were not at the location listed. Additionally, of those who were at the location listed, 8.8 percent were not willing to accept members enrolled in Blue Shield’s Covered California products, despite being listed as doing so.
• For Anthem, 12.5 percent of the physicians were not at the location listed in the provider directory and, that of those who were at the location listed, 12.8 percent were not willing to accept patients enrolled in Anthem’s Covered California products, despite being listed as doing so.
The DMHC has initiated a follow-up survey to assess if the plans have corrected the deficiencies identified in the initial survey reports.
Blue Shield
Agreement: http://wpso.dmhc.ca.gov/enfactions/docs/2428/1446507820233.pdf
Survey report: https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fsnr111814.pdf
Anthem
Agreement: http://wpso.dmhc.ca.gov/enfactions/docs/2432/1446568488109.pdf
Survey report: https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/303fsnr111814.pdf
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