Thirteen Anthem Plan Deficiencies Remain Uncorrected Four Years Later

California’s Department of Managed Health Care (DMHC) routinely surveys health plans in the state to ensure they are complying with the law. Outside of its routine, whenever DMHC has good cause to investigate issues of compliance with the law, it initiates an investigatory survey known as a non-routine survey.

In 2019, DMHC conducted one such non-routine survey of the Blue Cross of California dba Anthem Blue Cross dental health plan. In its final report issued in May 2020, the agency identified 21 uncorrected deficiencies. Anthem was put on notice that DMHC would conduct a follow-up review within 18 months to assess the status of those deficiencies. DMHC again notified Anthem of its scheduled follow-up survey in February 2021, asking Anthem to provide information regarding the status of the 21 uncorrected deficiencies noted in the final report.

A report on the agency’s non-routine survey follow-up was issued on November 1, 2023. In it, DMHC found that 13 deficiencies remain uncorrected, despite being noted several years ago. If this were a report card, correcting eight out of 21 deficiencies would give Anthem a D minus. Here is a look at some of the deficiencies that remain uncorrected as of DMHC’s last follow-up.

Quality Assurance

The follow-up survey addressed outstanding deficiencies in four areas: Quality Assurance, Grievances and Appeals, Utilization Management, and Language Assistance. Only one deficiency was noted in the Quality Assurance category, and likewise for Language Assistance. Four deficiencies were found uncorrected in the Utilization Management category, and all the rest belonged to Grievances and Appeals.

In the category of Quality Assurance, it was found that Anthem does not document that it reviews the quality of care provided, identifies problems, or takes effective action to improve care as needed. This deficiency remains uncorrected.

Grievances and Appeals

Out of 15 deficiencies in this category, Anthem had corrected six and left nine uncorrected. The uncorrected deficiencies are as follows:

1. Anthem does not ensure that it treats oral expressions of dissatisfaction as grievances and therefore does not ensure that those grievances are adequately considered and rectified.
2. Anthem’s exempt grievance log does not include the nature of the grievance and the nature of the resolution.
3. Anthem does not ensure adequate consideration and rectification of enrollee grievances.
4. When Anthem denies services based on medical necessity, it fails to describe the criteria used and the clinical reasons for its decision.
5. Anthem denials based on medical necessity do not include instructions and applications for the policyholder to seek an independent medical review (IMR).
6. When Anthem denies services based on a finding that the proposed service is not covered by the policy, it fails to specify the provision in the contract, evidence of coverage, or member handbook that allegedly excludes the service.
7. Anthem denials based on a finding that services are not covered fail to notify the enrollee about the right to seek an IMR.
8. Anthem does not include information required by law in its written grievance responses to enrollees, such as DMHC’s toll-free telephone number and TDD line for the hearing and speech impaired, Anthem’s phone number, and DMHC’s internet website address. The regulations plainly set forth the statement Anthem is required to use by law, yet they repeatedly fail to use it.
9. Anthem’s online grievance submission process doesn’t let enrollees preview and edit their grievance form before submitting it.

Utilization Management

Two deficiencies in this area had been corrected and two were left uncorrected. As with the grievance category, these uncorrected deficiencies severely hamper a policyholder’s ability to understand and fight a claim denial.

1. When denying service requests from healthcare providers based on medical necessity, Anthem does not consistently include a description of the guidelines used and/or clinical reasons for its decision.
2. Anthem’s explanation of benefits (EOBs) improperly instructs enrollees on how to file an appeal.

Language Assistance

Only one deficiency had been noted in this category, and it was found to be corrected in the follow-up survey. Anthem now provides the required notice of language assistance on all of its member grievance forms.

Is Anthem Mistreating You by Improperly Denying Claims or Requests for Healthcare? Gianelli & Morris Can Help.

Anthem is the largest insurance company in the state and covers more Californians than any other company when it comes to life, health, vision and dental plans. If Anthem is improperly denying you the coverage you are entitled to, you can fight to get the services you need and deserve. If the insurance company’s actions are deemed in bad faith, you can recover significant compensation for the harm they have caused, including punitive damages in appropriate cases. For help in Los Angeles or throughout California statewide, call Gianelli & Morris at 213-489-1600 for a free consultation with our team of experienced and successful California insurance lawyers.