California Fines Anthem, Blue Shield Over Inaccurate/Misleading Provider Directories

California Fines Anthem, Blue Shield Over Inaccurate/Misleading Provider Directories

 

On Tuesday, November 3 the California Department of Managed Health Care announced (DMHC) that it has fined two of the state’s largest insurers, Blue Shield of California and Anthem Blue Cross, over inaccurate provider directories for their plans sold through California's Health Exchange Covered California.

Anthem and Blue Shield account for almost 60 percent of patient enrollment in Covered California. Both insurers are also utilizing networks for their exchange/mirror products that are significantly narrower than their regular PPO networks. These narrowed networks, combined with inaccurate provider directories, have led to significant confusion and frustration for both physicians and patients.

Between January and May 2014, the DMHC Help Center received numerous complaints from Blue Shield and Anthem individual market enrollees who could not find a primary care physician in their area or alleged they had been misled by inaccurate health plan provider network directories.

In response, the agency via surveys found 18.2% of the physicians listed in Blue Shield’s provider directory were not at the location listed and 12.5% of the physicians were not at the location listed in the Anthem provider directory.

The survey also found of those who were at the location listed, 8.8% were not willing to accept members enrolled in Blue Shield’s Covered California products, despite being listed as doing so. For such Anthem providers, 12.8% were not willing to accept patients enrolled in the insurer’s Covered California products, despite being listed as doing so.

As a resulting of the findings DMHC fined Anthem $250,000 and Blue Shield $350.000.  State officials said that Blue Shield faced a higher fine because it was less cooperative with regulators.

In addition to the fines, DMHC has directed both plans to improve the accuracy of their provider directories and to also reimburse enrollees who may have been negatively impacted. Blue Shield reported has already reimbursed more than $38 million to enrollees who incurred out-of-network costs.

Both insurers will be required to report to DMHC the final number of enrollees who are reimbursed and the total amount. State officials said consumers should contact the insurers if they have questions or think they should receive reimbursement.

DMHC will be conducting a new survey of the insurers' provider networks to determine whether issues have been corrected.

(Sources:  CaliforniaHealthline.org  11/4/2015; HealthDive.org 11/3/2015)