California’s Department of Managed Health Care fined Blue Shield of California $800,000 due to grievance system issues that ultimately delayed complaint resolution.
In California, health plans are required to maintain a grievance and appeal system to address member complaints in a timely manner. State law requires health plans to supply details regarding member complaints to the DMHC, as well as respond to the department’s questions, within five calendar days, a Sept. 9 news release said. Members can file complaints with the DMHC if they disagree with a plan decision or it takes more than 30 days to hear back on a complaint.
In 121 instances from May 2024 through December 2024, Blue Shield of California did not respond to the DMHC’s inquiries in a timely and adequate way, according to the news release. This limited the DMHC’s ability to assess member issues. The plan’s late or incomplete submissions in response to DMHC inquiries affected 58 member complaints.
Along with facing the fine, Blue Shield of California will follow a corrective action plan and train staff on timely responses to the department’s requests.
“Blue Shield of California takes our regulatory obligations and commitment to members seriously. We respect the Department of Managed Health Care’s oversight role and have cooperated throughout this review,” Blue Shield of California told Becker’s. “We have already taken corrective actions to address the issues identified and remain focused on strengthening our processes and delivering the best possible experience for our members.”
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