California Fines Health Insurer for Mishandling Complaints of Delayed, Denied Claims

KQED Interview with Linda Winkler Garvin
December 17, 2024

Link to interview and article

By Katie DeBenedetti 

Anthem Blue Cross and Blue Shield office building in Woodland Hills, California, on July 7, 2022. The health insurer has paid a $3.5 million fine for failing to handle more than 10,000 member complaints in a timely manner over a two-year period, state officials said. 

As national scrutiny of health insurance intensifies, California officials have fined Anthem Blue Cross $3.5 million for mishandling member complaints over coverage denials and other issues. 

The fine stems from the company’s failure to handle more than 10,000 complaints from its members in a timely manner over a two-year period, according to the state’s Department of Managed Health Care. Patient care advocate Linda Winkler Garvin said such behavior can be medically dangerous for patients and strain their mental health as well. 

“It affects their life because many people — whether they [have] cancer or have chronic diseases or an acute problem  — need that authorization as soon as possible and within those required days,” she told KQED. “It’s deleterious to their health to not get these on time.” 

DMHC began investigating Anthem Blue Cross, also known as Blue Cross of California, after the company reported a large number of late acknowledgment and resolution letters. These are sent when a patient files a complaint, otherwise known as an appeal or grievance, after receiving a denial for health care services they requested or dealing with another delay or modification to their care. 

California law requires companies to acknowledge receiving the complaint within five days, but DMHC found that between July 2020 and September 2022, Anthem did not send acknowledgments of 11,670 member grievances within that window. More than 1,600 were not acknowledged for more than 51 days. 

Anthem also failed to resolve grievances and issue a written resolution within the standard 30-day window in many cases. More than 4,000 resolution letters were sent out late, including 1,630 after more than 51 days. 

Garvin said that there are many cases in which getting timely responses from health insurers is imperative. 

Patients who need medications to treat chronic or mental health conditions could lose progress if they are no longer able to get them covered by insurance. 

 “If there’s periods of weeks or days that the individual or the patient does not get that treatment because it’s delayed authorization, it just exacerbates the problem,” she said. 

There are also acute injuries or cancer diagnoses that require time-sensitive procedures. 

Plus, waiting on hold, following up on delayed claims or trying to get an explanation for why a claim was denied can be extremely stressful and frustrating for patients. 

“It affects them physically and emotionally,” Garvin said. “I’m talking to people, and they’re calling 12 times, 20 times and many times, people don’t get back to them. If they do, they say there’s a delay and don’t give a particular reason.” 

“It puts patients through an ordeal they should not have to go through,” she continued. 

Anthem said it has collaborated with DMHC to address the matter and takes member concerns seriously. DMHC said the company has paid the fine. 

“As part of our commitment to improving the member experience, we’ve made meaningful updates to our grievance and appeals process and invested in advanced system enhancements,” an Anthem Blue Cross spokesperson said. “These changes are designed to simplify the health care journey and better serve our members.” 

What to do with a New Cancer Diagnosis

Published in Brighter Magazine, January 2025

CLICK to download the published article

2020 was a lousy year. First, Covid-19 hit in March, quickly shutting the world down. Then in October, out of the blue, I was diagnosed with stage 2 ovarian cancer, shutting down my own world.  Before this time, as a nurse with 35 years of experience, I was aware that ovarian cancer often impacts many women of all backgrounds and is difficult to treat effectively. Despite knowing the facts, it never occurred to me that I would ever be one of those people.  

Prior to my diagnosis, I would characterize my health as excellent.  I had been a physically active woman for the last 50 years, eating a healthy diet and weighing in at the same weight I was at 18 years of age. Like so many others diagnosed with cancer, I was completely shocked to receive this news. 

Knowing how difficult it is to deal with overwhelming medical news, I decided to write an article that I hope is helpful when confronted with a cancer diagnosis. 

How to Proceed Forward with A Cancer Diagnosis 

When I was initially diagnosed, I found that, I needed to identify a “Care Partner” and/or a “Professional Health Advocate” to work with me. A care partner is someone who helps another individual. This individual/s may consist of one or more friends or relatives that can help a person newly diagnosed with cancer in several different ways. It can also be two or three special individuals who are interested in helping you and all of them can be considered care partners. In my situation my care partner was my husband.   

A patient advocate has the capacity to visualize how each aspect of care needs to be connected and in what way. A health advocate can communicate your health care needs to the medical team, help solve the pieces of the puzzle and provide necessary and customized health information. Their backgrounds can vary from an experienced former nurse or social worker, to someone who has taken classes at a university.  A professional health advocate, can be hired on an hourly basis to help you navigate your cancer journey. 

For clarification, the use of the word they refers to a health advocate and/or a care partner.  Who can play a vital role in navigating your healthcare. Here are some ways they can assist: 

• Advocacy: In situations where you might feel overwhelmed, they can speak to your medical team on your behalf to ensure your needs and preferences are addressed. 
• Research and Information Gathering: They can help gather information about medical conditions, treatments, and specialists, ensuring you are well-informed. 
• Emotional Support: They offer reassurance and companionship during stressful times, helping you cope with anxiety or uncertainty.   
• Appointment Management: They can assist in scheduling appointments and take you to your appointments. 
• Decision-Making Assistance: They can help you weigh the benefits and risks of different treatment options. 
• Available Resources: They can connect you with support groups, community resources, or additional services that may be beneficial.

Knowledge is Power 

Understanding your diagnosis is crucial for making informed decisions about your care. Here are some tips for approaching your research effectively: 

• Start with Trusted Sources: Organizations like the National Cancer Institute, Mayo Clinic, and the American Cancer Society offer credible, evidence-based information. 
• Focus on Your Specific Diagnosis: Look for materials that address your specific condition, as treatment and management can vary widely. 
• Understand Treatment Options: Research different treatment modalities, including standard treatments and emerging therapies, to explore what might be best for you. 
• Clinical Trials: Investigating clinical trials can provide access to cutting-edge treatments and additional support. 
• Beware of Misinformation: Be cautious of information from unverified sources, especially on social media, as it can be misleading. 

Consider getting a second or third opinion. 

You may want to consider another opinion to confirm your diagnosis and treatment plan to ensure it is accurate and appropriate. Another physician may have a different approach or insight that could lead to better options.  A second opinion may also provide some reassurance on what you have been informed.  

Based on your research and information from your second opinions, you can discuss these findings with your healthcare team. This can foster collaborative discussions and ensure all your questions are addressed. 

Type up an Agenda for each Physician Appointment  

A written or typed agenda will help keep you focused and make sure all your questions are answered, while guiding you through the items you need to discuss. My success on getting questions answered was dependent on my preparation.  If you conduct your medical appointments like a business meeting it will help you take control of your appointment. Not only does it demonstrate your commitment to participate in your care, it reminds you of the agenda items you wish to discuss. 

My patients have benefited from writing a list of benefits and risks for each treatment recommended and reviewing the list with members of their medical team, along with family members so they can make the best decisions. 

Post Treatment Support 

Transitioning after cancer treatment can be a profound journey, and it is essential to be kind to yourself and take the time you need to adjust.  Support from your friends and loved ones will be needed at this time.  This period will be different for each person and may be ongoing. Learn about Survivorship by educating yourself about what to expect post-treatment. Resources from organizations like the American Cancer Society or The National Cancer Institute can be helpful. 

Embracing the mindset of a survivor can indeed empower individuals facing a cancer diagnosis. It fosters resilience and encourages proactive changes that contribute to both physical and mental well-being. Focusing on what you can control—like lifestyle changes, support systems, and positive thinking—can make a significant difference in your journey. 

Since navigating life after cancer treatment can be challenging, both physically and emotionally, it is normal to feel a mix of relief, anxiety or sadness after your treatment is completed.  Speaking with a professional can help you process your experiences and feelings.  In addition, getting connected with a support group can provide comfort and understanding when others have gone through similar experiences. 

Focusing on a nutritious diet that is rich in fruits and vegetables and lean proteins can be helpful.  I consulted with a nutritionist which I found to be very beneficial. Engaging in regular exercise tailored to your ability can help improve your mood and physical health.  

It’s now 2024 and things are looking brighter. Covid-19, for the most part has been downgraded to a flu like disease and I am free of cancer.  

I was fortunate enough to get an early diagnosis and early treatment. By taking an active role in your cancer care, you can feel more empowered and engaged in your treatment journey. My background as a registered nurse and currently as a health advocate have shown me how informed and engaged individuals with cancer can feel when they are part of the decision-making process.  

Cancer often acts as a wake-up call, prompting us to reflect on our priorities and what truly matters. Engaging in activities that bring joy and fulfillment can boost resilience and improve overall well-being. Whether it is spending time with loved ones, pursuing hobbies, or exploring new passions, embracing what you love can make a significant difference in your outlook.      

Linda Winkler Garvin, MSN 
Health Advocacy & Consulting 
President & Founder, Patient Advocate Bay Area, Inc. 
Ambassador & Advocate for The Clearity Foundation 
E-mail:  lindawgarvin@gmail.com 
Phone:   (510) 520-0186 

The Importance of Early Detection in Ovarian Cancer

  “Ovarian cancer is a serious and potentially deadly disease.”

“MY STORY” 

Part 1:  What Are The Signs of Ovarian Cancer 

I’ve been a medical professional for over 30 years and consider myself to be quite knowledgeable about diseases, symptoms, and risk factors, especially for the population with whom I have worked the most - middle aged and older adults. Before I was diagnosed with ovarian cancer, I knew some information about it. Mostly, I was aware that ovarian cancer often impacts people over 50 and it is difficult to treat effectively. Despite knowing the facts, it never occurred to me that I would ever be one of those people. Prior to my diagnosis, I would characterize my health as excellent.  I had been a physically active woman for the last 50 years, eating a healthy diet and weighing in at the same weight I was in high school. Like so many others diagnosed with ovarian cancer, I was completely shocked to receive this news.

 

I quickly found out how much I didn’t know. Recent statistics from The American Cancer Society reveal that ovarian cancer ranks as the 15th most common cancer and the sixth leading cause of cancer-related deaths among women. Furthermore, a woman's lifetime risk of developing ovarian cancer is reported to be 1 in 87.   

I asked myself how I could have a cancer and not know it. I discovered ovarian cancer is often diagnosed at an advanced stage because early symptoms can be subtle or absent, making early detection difficult. Vaginal bleeding was my only symptom. This led me to call my gynecologist, who quickly ordered a vaginal ultrasound which found a large ovarian tumor. Based on my oncologist’s recommendations, I decided to undergo a total hysterectomy.  My pathology report indicated that I had a highly aggressive tumor and chemotherapy was ordered.  

I was fortunate enough to get an early diagnosis and am cancer free at this time. 

Here are some common symptoms that may be associated with ovarian cancer: 

1. Pelvic or abdominal pain: Persistent pain or discomfort in the pelvic or abdominal region.  
2. Bloating: Feeling consistently bloated, especially if it persists for more than a few weeks. 
3. Trouble eating or feeling full quickly: A sudden change in appetite, difficulty eating, or feeling full despite eating very little.  
4. Frequent urination: Increased urgency to urinate and more frequent bathroom trips. 
5. Unexplained Vaginal bleeding: Report this to your gynecologist immediately.  
6. Changes in bowel habits: Any significant changes in bowel habits, including constipation or diarrhea.  
7. Unexplained weight gain or loss: Sudden and unexplained changes in weight can be a symptom of various health issues, including ovarian cancer. 
8. Fatigue: Feeling unusually tired or having low energy levels consistently. 
9. Back pain: Pain in the lower back. 

It is also crucial to note that these symptoms can be indicative of various conditions, and experiencing them does not necessarily mean someone has ovarian cancer. However, if these symptoms are persistent and unexplained, for several weeks, it is important for individuals to consult with a healthcare professional, particularly a gynecologist. 

Part 2:  Ovarian Cancer--What Are The Chances? 

Remember that early detection is associated with higher survival rates.  

In Part 1, I shared the statistic that a woman's lifetime risk of developing ovarian cancer is reported to be 1 in 87.  However, I learned there are factors which can increase an individual’s risk. 

For example, women of Ashkenazi Jewish descent, like me, are at a higher risk.  For this reason, it is vital to know your familial history. If you have a family history of breast, uterine, ovarian, or colorectal cancer this increases your risk.  

Your family medical history can provide valuable information about potential genetic or hereditary risks for various health conditions, including ovarian cancer. Many health conditions, including certain types of cancer, can have a genetic component.

The BRCA1 and BRCA2 genes are critical in understanding the genetic risk factors for certain cancers, including breast and ovarian cancers. Mutations in these genes, or in other genes such as PAL2 or RAD51C/D,  can significantly increase the risk of developing these cancers. Individuals with a strong family history of breast and ovarian cancers should consider genetic testing to identify mutations in these genes. Genetic counselors are experts who can help you 

understand your genetic testing results, clarify risks for additional cancers and support you in the process of sharing your results with relatives and children.  

Mutations in BRCA1 and BRCA2 are about 10 times more common in those who are Ashkenazi Jewish than those in the general population.  The lifetime ovarian cancer risk for women with a BRCA1 mutation is estimated to be between 35% and 70%. 

Age is a significant risk factor in developing ovarian cancer, and the risk tends to increase with age, especially after menopause.  However, it is important to note that having one or more risk factors does not guarantee that an individual will develop ovarian cancer, and many women with ovarian cancer have no known risk factors. 

Factors that may increase your risk for ovarian cancer: 

• A family history of ovarian, breast, uterine or colorectal cancer 
• Increased age 
• Genetic mutations in your BRCA1 or BRCA2 genes 
  https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet 
• Being post-menopausal 
• Ashkenazi Jewish decent  

Factors that can decrease your risk for ovarian cancer: 

• The use of oral contraceptives 
• Pregnancy 
• Breastfeeding 

It’s important to stress that some women diagnosed with ovarian cancer have no known risk factors. If you think you may be at risk, I urge you to speak with your doctor, preferably your gynecologist. 

The most important message I have is to be vigilant and advocate for your health and your health care. Be attuned to any unusual or persistent symptoms mentioned above, and if they persist for more than a few weeks, take proactive steps to seek medical attention. Your awareness and proactive approach can make a significant difference in early detection and overall health outcomes. 

Knowing the symptoms and risk factors associated with ovarian cancer, coupled with undergoing annual gynecological check-ups can lead to a diagnosis at an earlier, more treatable stage. Furthermore, we can all advocate for research to enhance screening methods and develop more effective treatments to minimize the impact of ovarian cancer on women's health. 

If you or someone you care about has been diagnosed with ovarian cancer, below are some resources I have found valuable: 

• Ovarian Cancer Research Association Foundation; https://ocrahope.org/
• National Ovarian Cancer Coalition; https://ovarian.org/ 
• The National Cancer Institute; https://www.cancer.gov/ 
• The Clearity Foundation; https://www.clearityfoundation.org/ 
• Nancy’s list; https://nancyslist.org/ 
  Nancy’s list is one of the most comprehensive and valuable catalogs of resources I have come across. 
• The Society of Gynecologic Oncology; https://www.sgo.org/ 
• Center for Advancement of Cancer Education; https://beatcancer.org/ 

Sources:   

• American Cancer Society. (2021). Ovarian Cancer Risk Factors.
• Centers for Disease Control. (2024). Jewish Women And BRCA Gene Mutations.
• Ovarian Cancer Research Alliance. (ND). Causes And Risk Factors. 
• MD Anderson. (2017). How To Lower Your Ovarian Cancer Risk. 

© Linda Winkler Garvin, MSN 

Health Advocacy & Consulting

President & Founder, Patient Advocate Bay Area, Inc. 

Ambassador & Advocate for The Clearity Foundation 

STS Progran for OCRA 

 

E-mail:    lindawgarvin@gmail.com 

Phone:     (510) 520-0186 

Web:        patientadvocatebayarea.com