June 21, 2018
Area(s) of Interest: Advocacy Payor Issues and Reimbursement
In March, the California Medical Association (CMA) asked the Department of Managed Health Care (DMHC) to investigate Anthem Blue Cross’ systematic failure to publish effective dates for its 241 different medical and clinical utilization management policies. Without clearly posted effective dates, the published policies cause confusion and misinform physicians and patients who have no timely 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.
CMA asked DMHC to look into this issue, and to require that Anthem add easily identifiable effective dates to its policies and to clearly indicate whether a posted policy is in effect in California.
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.
DMHC recently informed CMA that the agency is working with Anthem regarding the processes it uses when deploying clinical guidelines in California. DMHC has directed Anthem to include effective dates on all its guidelines and to ensure that its portal clearly notes whether particular guidelines apply in California.
In response, Anthem indicated to DMHC that it has updated its national portal to direct providers to the appropriate state portal for state-specific guidelines. However, it does not appear that Anthem has fully complied with the DMHC order. While Anthem has published a document titled, “Clinical UM PPO Guidelines for California” on its state portal that includes effective dates, the national portal does not direct physicians back to the state portal for effective date information on its various policies as the payor stated to DMHC.
CMA has alerted DMHC to this concern and the department is looking into it further.