California Department of Managed Health Care
(Sacramento) – The California Department of Managed Health Care (DMHC) has taken enforcement actions including a $322,500 fine against California Physicians’ Service (Blue Shield of California) and a $135,000 fine against Care 1st Health Plan for failing to identify, timely process, and resolve consumer grievances. The plans have also failed to fully and timely provide information to the Department during the investigation of these consumer complaints.
“The health plan grievance and appeals process is structured to ensure that consumer complaints are resolved in a timely manner, and that consumers are made aware of their right to appeal to the DMHC,” said DMHC Director Shelley Rouillard. “Blue Shield of California and Care 1st Health Plan must improve their grievance and appeals systems to better address consumer complaints and protect the health care rights of their enrollees.”
The DMHC identified 34 cases involving 61 consumer grievance system violations for Blue Shield of California and 18 cases involving 30 consumer grievance system violations for Care 1st Health Plan. In these cases, the health plans deprived consumers of their grievance and appeals rights and/or failed to fully and timely provide information to the Department during the investigation of member complaints.
For additional information on these enforcement actions, visit the links below:
Blue Shield of California:
http://wpso.dmhc.ca.gov/
Care 1st Health Plan:
http://wpso.dmhc.ca.gov/
In California, consumers have many health care rights, including the right to know why a plan denies a service or treatment, and the right to file a grievance if they disagree.
Health plans are required to have grievance and appeals systems to assist consumers in resolving these issues. A health plan’s grievance program informs consumers of their full grievance and appeal rights and the protections afforded to them under the law, including the right to pursue an Independent Medical Review or file a complaint with the DMHC if they are dissatisfied with their health plan’s decision.
A robust grievance program also allows health plans to track and trend grievances for the purpose of uncovering systemic problems, thereby providing the opportunity for quality improvement.
If a consumer is experiencing an issue with their health plan or is having difficulty accessing care, they can file a grievance with their health plan. If they are not satisfied with their health plan’s resolution of the grievance or have been in their plan’s grievance system for 30 days, they should contact the DMHC Help Center for assistance at 1-888-466-2219 or online at www.HealthHelp.ca.gov.