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CMA asks DMHC to require Anthem to publish effective dates for clinical policies

March 07, 2018
Area(s) of Interest: Commercial Payors Professional Development & Education 


Unlike all other major payors in California, Anthem Blue Cross does not disclose on its website the effective dates for its 241 different medical and clinical utilization management policies, which dictate the medical services Anthem will cover for its enrollees. Physicians and their patients, therefore, have no timely or effective method to determine which of Anthem's published policies are effective or what medical services are covered for purposes of providing clinical care, determining cost sharing arrangements, and evaluating the breadth of Anthem's coverage.


This issue came to light when Anthem published a  concerning clinical guideline that restricts the use of intravenous anesthesia to sedate patients during cataract surgery. In a complaint to the Department of Managed Health Care (DMHC), the California Medical Association (CMA) expressed concern that the drastic change in policy would cause significant patient safety concerns and put patients at risk of serious complications, including blindness. CMA asked DMHC to investigate Anthem’s policy restricting use of sedation during cataract surgery.


In response to CMA’s complaint on the new policy, Anthem clarified that while the policy was published on December 27, 2017, and then revised and re-published on February 1, 2018, the policy has not been implemented and is not yet in effect for California.


CMA has now asked DMHC to require that Anthem, on a prospective basis, add an easily identifiable effective date to its policies to clearly indicate whether a posted policy is in effect in California.


Without the effective date, the published policies cause confusion and misinform patients, consumers and all providers. CMA also believes that Anthem’s practice of not disclosing the effective dates violates Health & Safety Code §1363.5(a), which requires plans to disclose to DMHC and to network providers the process the plan uses to authorize, modify or deny health care services under the benefits provided by the plan. Plans must also disclose this information to enrollees upon request.


“Anthem's method of publishing all of its national medical policies on its California website without identifying whether they are effective for its California products is not only confusing but makes it nearly impossible for providers, enrollees and regulators to effectively monitor or assess what medical services it does cover in California,” wrote CMA President Theodore M. Mazer, M.D., in a letter to DMHC.


CMA has asked DMHC to look into this issue, and we will publish an update when additional details are available.

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