By Zoe Bulls
In an enforcement action against two health plans, the California Department of Managed Healthcare (DMHC) fined Blue Cross of California Partnership Plan, Inc. and Blue Cross of California (Anthem Blue Cross) a combined $8.5 million for violating state laws that require health plans to address claims payment disputes from doctors, hospitals, and other health care providers in a timely manner.
DMHC’s Office of Enforcement (OE) initiated investigations into the plans in 2019 after it received health care provider complaints. Both health plans failed to acknowledge receipt of and failure to timely issue written determinations in response to health care provider claims payment disputes, according to the complaints. OE determined that both health plans failed to adhere to California Code of Regulations title 28 section 1300.71.38(e)(1), (e)(2), and (f).
Title 28 section 1300.71.38(e)(1) of the California Code of Regulations requires health plans to identify and acknowledge each provider dispute within two working days of receiving an electronic provider dispute. Subdivision (e)(2) requires a health plan to identify and acknowledge each provider dispute within 15 working days of receiving a paper dispute. OE’s investigations revealed that Blue Cross of California Partnership Plan failed to acknowledge 68,158 provider disputes within the required timeframe. Anthem Blue Cross violated the same regulations by failing to acknowledge 30,797 provider disputes on time.
California Code of Regulations title 28 section 1300.71.38(f) requires health plans to resolve each provider dispute and issue a written determination of the relevant facts and reasons for the plan’s determination within 45 working days of receiving the dispute. OE’s investigations found that Blue Cross of California Partnership Plan failed to resolve 15,740 provider disputes in a timely manner, and Anthem Blue Cross violated the regulation by failing to resolve 16,895 provider disputes in a timely manner.
Blue Cross of California Partnership Plan, Inc will pay DMHC a $5 million fine for its violations, and Anthem Blue Cross will pay a $3.5 million fine. In addition to these penalties, both health plans will implement Corrective Action Plans (CAPs) to prevent further violations. The CAPs will include requirements for the health plans to monitor provider disputes more regularly, remove barriers that delay provider dispute resolutions, and increase staffing on provider dispute teams.