The California Department of Managed Health Care has hit Anthem Blue Cross with $1.1 million in fines over two legal violations that the agency says drove up costs for patients.
The department issued a $750,000 fine for incorrectly applying office visits to some members' deductibles, which impacted more than 6,500 people between 2015 and 2020. The insurer will also pay a $360,000 fine for failing to mail out an explanation of benefits document to more than 363,000 members in 2019.
The agency said that Anthem Blue Cross has agreed to multiple corrective actions to address the issues, including reimbursing the affected members for costs incurred when office visits were not properly excluded from the deductible to the tune of $9.2 million in payouts.
"The DMHC's enforcement actions against Anthem Blue Cross are a strong reminder that the Department will hold health plans accountable to the law, and protect consumer's health care rights," said DMHC Director Mary Watanabe, in a statement.
"These violations had financial impacts to enrollees, and deprived enrollees of information on their rights to file a complaint or apply for an Independent Medical Review with the DMHC Help Center," Watanabe said. "Anthem Blue Cross has agreed to take corrective actions including reimbursing impacted enrollees and updating the plan’s policies to make sure these issues do not happen again."
Health plans are required to issue EOBs to members to ensure that they have information on their own payment obligations, making it easier for them to track out-of-pocket costs for the year. It also includes key information such as appeals rights.
In addition to the reimbursements, Anthem Blue Cross said it will take other actions to ensure these issues do not crop up again in the future, DMHC said.