CMA asks DMHC to investigate Anthem’s failure to comply with provider directory law

March 02, 2020
Area(s) of Interest: Practice Management Advocacy 

The California Medical Association (CMA) has submitted a formal complaint to the California Department of Managed Health Care (DMHC) asking that the agency investigate Anthem Blue Cross’ failure to comply with California’s law requiring that health plans publish and maintain accurate provider directories.

The law (SB 137)—which took effect in July 2016—was intended to provide patients with more accurate and complete information to identify which providers are in their payor’s network. It requires health plans to comply with uniform standards, and provide timely updates, for their provider directories.

However, in September 2019, more than three years after the law became effective, CMA identified that the Anthem online provider directory did not meet this requirement. Specifically, Anthem’s provider directory does not allow enrollees contemplating care from Sutter Health to rely on the accuracy of the directory when making health care decisions.

CMA has also identified that Anthem’s directory does not allow for a search using a reasonable combination of search elements, which is a requirement of the Uniform Provider Directory Standards. Patients with an HMO are not able to search for a specific specialty that is in their specific medical group/IPA, which is how most enrollees would search for providers.  

It is imperative that health plans publish accurate, complete provider directories to ensure that the public, enrollees, potential enrollees, and providers can easily identify in-network providers in the enrollees’ health plan. Without these directories, consumers are unable to make informed decisions when purchasing coverage or selecting a treating provider and physicians are inhibited from identifying in- network specialists for purposes of referrals. Both situations potentially lead to unintended use of out-of-network providers and higher out-of-pocket costs for consumers, which is the very situation SB 137 is meant to remedy.

CMA has urged DMHC to promptly investigate and to take swift action to ensure that Anthem complies with California laws that are designed to protect health care consumers and providers.

For more details, see CMA’s complaint.


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