Blue Shield of California fined for mishandling claims payments for medical care
SACRAMENTO - The California Department of Managed Health Care (DMHC) has fined Blue Shield of California $300,000 for mishandling numerous claims payments and delaying reimbursements to a plan member over a five-year period.
What we know:
The California Department of Managed Health Care (DMHC) has levied a $300,000 fine against California Physicians’ Service (Blue Shield of California).
This penalty is due to the company's mishandling of several claims payments and delaying reimbursement payments to a plan member for approved medical care over a five-year period.
Blue Shield of California has paid the fine and has implemented corrective actions to improve its claims processing.
The backstory:
Blue Shield of California had approved a health plan member’s request for speech and occupational therapy from an out-of-network provider at the in-network rate. However, the plan then denied or mishandled payments for 36 claims related to these services from 2020 through 2024.
This resulted in the incorrect denial or reimbursement of incorrect amounts to the member for approved medical services for years.
In response, the member’s parent filed 10 separate complaints with the DMHC Help Center.
The DMHC Help Center resolved these complaints and referred the matter to the Department’s Office of Enforcement for further investigation.
What they're saying:
DMHC Director Mary Watanabe stated, "Health plan members have rights, and are protected under some of the strongest patient protection laws in the country."
She added, "The DMHC will continue to protect health plan members’ rights, just like in this case where the member came to the DMHC Help Center because Blue Shield of California mishandled dozens of payments for medical care. I encourage plan members to file a complaint, and reach out to the DMHC Help Center, if they are having problems getting care or facing billing or payment issues with their health plan."
What you can do:
The DMHC encourages health plan members experiencing problems with their health plan, including billing and copay disputes, denials of claims, or delays in finding an in-network doctor or provider, to first file a complaint, also called an appeal or grievance, with their health plan.
If the member does not agree with their health plan's response or the plan takes more than 30 days to resolve the grievance in non-urgent cases, the member should contact the DMHC Help Center.
If a health plan member is experiencing an urgent issue, they should contact the DMHC Help Center immediately.
The DMHC Help Center can be reached at www.DMHC.ca.gov or by calling 1-888-466-2219.
The Source: Information for this story is from the California Department of Managed Health Care (DMHC).