Anthem, Blue Shield Fined Over Misleading Provider Directories

On Tuesday, the California Department of Managed Health Care announced that it has fined Blue Shield of California and Anthem Blue Cross over inaccurate provider directories for their plans sold through Covered California, the Los Angeles Times reports.

Details of Fines

DMHC Director Shelley Rouillard said the agency "has taken enforcement action and fined Blue Shield and Anthem due to unacceptable inaccuracies in their directories," adding that they "limited enrollee access to care that resulted in an unacceptable consumer experience and must be fixed."

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.

DMHC spokesperson Rachel Arrezola said, "There was a lack of timeliness in receiving responses and overall cooperation from Blue Shield, so the fine was a little higher."

Other Enforcement Actions

In addition to the fines, DMHC has ordered both insurers to:

• Improve the accuracy of their provider directories; and
• Reimburse enrollees who have been negatively affected by the inaccurate information.

According to the Times, Blue Shield already has reimbursed more than $38 million to consumers who had been charged out-of-network costs. Officials said they do not yet have a reimbursement estimate for Anthem.

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.

According to the Times, DMHC is conducting a new survey of the insurers' provider networks to determine whether issues have been corrected.

Insurers' Response

Anthem and Blue Shield both acknowledged mistakes were made as they prepared their policies for the rollout of the Affordable Care Act.

Anthem spokesperson Darrel Ng said, "During this time of unprecedented change and despite Anthem's continual efforts to improve the accuracy of the system, Anthem's provider directory inadvertently listed some providers," noting, "In the last two years, Anthem has spent more than $4 million improving the provider directory to make it more user-friendly and to improve the accuracy of the data."

Meanwhile, Blue Shield in a statement said it "believes this agreement is in the best interest of our members. The settlement addresses past issues raised in 2014, and our members should not be concerned about their current plan or its networks" (Terhune, Los Angeles Times, 11/3).