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.” 

Six Essential Items When Communicating with the Insurance Company

Despite the best efforts of most doctors, claims are frequently denied due to information that is inaccurate or missing from your medical forms/bills that are submitted by the doctor’s office to the insurance company. To help avoid unnecessary claim denials, have the following six items available for all written and phone communications, as well as hospital or health related visits.

• Group insurance name and policy number.
• Insurance identification number
• Date of birth
• Date health coverage commenced
• Your social security number
• The name, social security number and date of birth of the person who is the main policy holder

Reducing the Chances of Claims Being Denied

At the onset, it is fundamental to thoroughly understand your health insurance policy. Knowing what is covered and not covered will reduce the number of conflicts you will encounter with your provider. In particular, it is important to know the following information about your health insurance to reduce your chances of having a claim denied.

1. First and foremost, be aware of what conditions are covered, along with the limitations of your policy.
2. Determine if an authorization is required for specialized services or an inpatient hospital stay.
3. Know the maximum benefit coverage.
4. If you cannot find the answer in your policy or if you don’t understand the wording, contact the insurance company to clarify anything that is not clear or that you don’t understand.
5. Another good practice is to contact the doctor’s office before an appointment is made to make sure he/she still has a contract with your provider, since the web site or the printed sheet of listing physicians may not always be up to date.
6. Also, be aware that when you receive a written authorization for a specific procedure, surgery or physical therapy, there is usually a specific time frame given with a beginning and ending date. The authorization will not be valid and payments will not be made if you do not adhere this “window of time” listed in your authorization letter.

Insurance Essentials You Need to Know

Anyone who has ever attempted to get approval from a health provider to see a specialist or start on a new medication or treatment knows the overwhelming and frustrating challenges that can be encountered. It may be difficult, for example, for patients suffering chronic pain to obtain coverage for medical or alternative procedures such as acupuncture or guided imagery, or certain types of medications. The purpose of this article is to highlight some important things to know about your health insurance policy, as well as provide some tips for communicating with your insurance representative.

Whether you are requesting information about your current insurance plan or are applying or transferring to a new plan, it is essential to understand the benefits and limitations of your insurance policy. Although there are numerous pieces of information to review and questions to ask your insurance carrier, some of the conflicts, with insurance carriers, that individuals with chronic health problems have shared with me over the years, have led me to highlight a few of the most critical concerns.

Each year your insurance company can make major policy changes. These changes usually commence at the beginning of the calendar year, but occasionally could occur throughout the year. In addition, a specialist previously covered by your health plan that you have been considering making an appointment with could decide to discontinue their contract with the insurance carrier during the year due to a business change in their group practice. If you are considering going to a new physician, always review your insurance plan by checking their web site or by phone to check if this physician is still in your provider network.

One significant area frequently neglected by many people is remembering to keep up to date with your health insurance coverage plan and any policy changes that have taken place from one year to the next. For example, if there are any changes in your marital status, new dependents or any changes made to your plan during open enrollment at your work place, you need to contact your insurance company and ask how you would make these additional changes or revise your current health plan to ensure you will have the coverage you need and want.

In order to be prepared in dealing with health insurance providers, there are a few basic questions that need to be answered.

First, are the current medical providers and the hospital you currently utilize included in your plan’s network?

Second, do you need authorization from your Primary Care Provider to see a specialist?

Third, if you choose a physician outside the provider’s network, will you be covered?

And finally, can you change Primary Care Providers?

In addition, if you need to be admitted to the hospital or go to a clinic for a procedure, always confirm that all of the medical providers [i.e. anesthesiologist, radiologist, hospitalist, specialist…], including the facility is contracted with your health plan. The facility or the individual physicians may have their own billing system. If so, they need to be contracted with your health plan to be considered as an in-network provider.

Six Essential Items When Communicating with the Insurance Company
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