DMHC Enters Settlement With Blue Shield of California and Blue Cross of California dba Anthem Blue Cross

By Scott Glovsky on November 5th, 2015 in Class Action, Insurance Bad Faith

Yesterday, the California Department of Managed Healthcare (“DMHC”), the California body charged with regulating managed health care plans, announced settlement agreements with Blue Shield of California and Blue Cross of California dba Anthem Blue Cross to resolve issues that the DMHC found with these insurers’ narrow networks for individual ACA compliant health plans and the way that these insurers misrepresented their networks to the public. The agreements are similar, yet the ways that they differ drastically affect the benefits that the agreements will bring to the public.  Specifically, the agreement with Blue Shield of California is largely ineffective and provides no meaningful benefit to the public while the agreement with Blue Cross of California dba Anthem Blue Cross in sharp contrast leaves open the possibility of positively affecting the public.

The Blue Shield of California settlement forces Blue Shield to provide only partial relief to consumers. The hallmark of this agreement is that Blue Shield agreed to allow members to file claims for services that they received from out of network providers in 2014 and Blue Shield will then reprocess those claims. Blue Shield claims in the agreement that it has already to date reprocessed millions’ worth of claims but the agreement does not provide any explanation for how Blue Shield’s figure was determined and what exactly is included in the figure. The number is highly suspicious. While the reprocessing of claims will likely provide some benefit to the public, the period of time for which Blue Shield will accept claims is very limited and it is unlikely that Blue Shield will fully compensate member costs that arose out of Blue Shield’s wrongful conduct.

For example, it is likely that Blue Shield will not compensate people for the injury that they have suffered to their credit. It is also unlikely that Blue Shield will fully compensate people who paid out of network doctors at the doctor’s billed rate, as opposed to Blue Shield’s negotiated rate. Further, as past experience and history has shown, claims processes like the one that is implemented in these agreements are inherently flawed in that there is almost always low participation rate. Whether it be because people do not understand the claims process, do not have time for the claims process, or do not receive adequate notice of the process, wide numbers of victims are generally left out of claim procedures and do not receive the compensation to which they are owed.

In contrast, the agreement into which the DMHC entered with Blue Cross of California dba Anthem Blue Cross allows members to seek compensation through a class action lawsuit that the Law Office of Scott Glovsky and other attorneys filed.  This allows us the opportunity to fight for relief that will provide the best possible recovery for all members of the class and to do so in a way that does not leave any portion of the consumers out.

The Law Office of Scott Glovsky and other lawyers also continue to pursue a class action lawsuit against Blue Shield of California. It is our hope that we continue to fight for the relief for consumers that is left out of the DMHC settlement.