The California Department of Managed Health Care (DMHC) has fined Anthem Blue Cross $8.5 million for failing to address claims payment disputes in a timely manner from doctors, hospitals, and other healthcare providers.
California law requires that health plans have a provider dispute resolution process whereby providers can submit a dispute related to the payment of claims for healthcare services provided to plan members, DMHC noted.
California law also requires that health plans acknowledge provider disputes within two working days for electronic provider disputes and 15 working days for paper provider disputes and to resolve provider disputes within 45 working days, DMHC said. Within five working days of a written decision in favor of the provider, the plans must pay past-due payments, including interest and penalties.
"In this case, the plans failed to acknowledge a total 98,955 provider disputes within the required time frames, and a total of 32,635 provider disputes were not resolved in a timely manner," DMHC explained.
DMHC said the plans agreed to pay the penalties, which include a $5 million fine for the Blue Cross of California Partnership Plan and a $3.5 million fine for Blue Cross of California. In addition, the plans are taking corrective actions to improve response times to provider disputes.
A letter of agreement about the matter dated September 26 stated that all corrective actions to address the systemic issues related to the timely acknowledgment and resolution of provider disputes are ongoing and not fully implemented, but they are expected to be completed before December 31, 2024. Those actions included changing monitoring performance metrices from monthly to weekly, conducting daily inventory reviews to ensure older disputes were resolved timely, and removing barriers that prohibited resolution.
Read the full statement here. Read the letter of agreement here.
