CA Gov, Department of Managed Healthcare: DMHC Fines Blue Cross of California Partnership Plan, Anthem Blue Cross $8.5 Million for Mishandling Payment Disputes from Doctors, Hospitals & Other Providers  

September 27, 2024 

(Sacramento) – The California Department of Managed Health Care (DMHC) has taken enforcement actions, including a total of $8.5 million in fines, against Blue Cross of California Partnership Plan, Inc. and Blue Cross of California (Anthem Blue Cross) for failing to address claims payment disputes in a timely manner from doctors, hospitals and other health care providers. The plans agreed to pay the penalties, which include a $5 million fine for Blue Cross of California Partnership Plan, Inc. and a $3.5 million fine for Anthem Blue Cross. In addition, the plans are taking corrective actions to improve response times to provider disputes. 

“Health plans are required to acknowledge and resolve provider payment disputes promptly and accurately from doctors, hospitals and other health care providers,” said DMHC Director Mary Watanabe. “Failing to address provider disputes on time can impact the financial stability of providers and the overall stability of the health care delivery system, which ultimately can impact patient care.”

PROTECTIONS FOR PROVIDERS: To ensure the health care delivery system can continue to provide services to health plan members, it is important doctors, hospitals and other providers receive accurate payments from health plans in a timely manner. California law requires health plans have a Provider Dispute Resolution (PDR) process whereby providers can submit a dispute related to payment of claims for health care services provided to plan members. Additionally, California law requires 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. 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 timeframes, and a total of 32,635 provider disputes were not resolved in a timely manner. By health plan, Blue Cross of California Partnership Plan, Inc. failed to acknowledge 68,158 provider disputes within the required timeframe and did not resolve 15,740 provider disputes in a timely manner, and Anthem Blue Cross failed to acknowledge 30,797 provider disputes within the required timeframe and did not resolve 16,895 provider disputes in a timely manner.

PLANS TAKE CORRECTIVE ACTION: Blue Cross of California Partnership Plan, Inc. and Anthem Blue Cross have acknowledged their failure to comply with the law and agreed to pay the penalties and complete Corrective Action Plans (CAPs) to settle the issue. The CAPs include monitoring provider disputes more regularly, removing barriers that delay provider dispute resolutions, and adding staff to provider dispute teams.  

WHAT PROVIDERS CAN DO: Health care providers looking for more information or to dispute a payment with a health plan can visit the DMHC website Provider Complaint page.

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