“Ignorantia juris non excusat” or “ignorance of the law is no excuse” has hit some insurance companies hard so far in 2022. Whether it was ignorance, lack of oversight, or something more nefarious, state agencies are cracking down on insurance companies that are running afoul of the rules.

Georgia

After Georgia Insurance Commissioner received approximately 78,000 complaints in five years about Anthem Blue Cross Blue Shield (ABCBS), action had to be taken. The primary issue? Patients were told that doctors were in-network when they weren’t, leading to much higher out-of-pocket costs. Additionally, ABCBS was not replying to consumer complaints in a timely manner and had improper claims settlement practices in place. All of this led Georgia to issue their largest fine to date in March 2022: $5 million. ABCBS submitted a corrective plan of action to the state which included replacing the database system with one that corrects the issues and offers improved accuracy and transparency. The company has also promised to develop a new process for handling complaints, to pay claims within the timeframes established by Georgia law, and load provider in-network contracts in a timely manner.

Colorado

The Colorado Division of Insurance (DOI) announced in April 2022 that it was fining Bright Health $1 million and is entering into a formal agreement with the company to address its issues with both health care providers and consumers. More than 100 complaints were received by DOI about four primary concerns:

  1. Failure to pay provider claims;
  2. Failure to communicate with members;
  3. An inability to accurately process consumer payments; and
  4. Slow claims processing for physical and behavioral health coverage.

Half of the penalty was paid immediately. The remaining $500k is dependent upon Bright Health’s progress toward paying past claims accurately, resolving complaints in a reasonable time frame, settling claim disputes with health care providers, and a substantial reduction in complaints received by the DOI. If they meet these requirements by April of 2023, the remaining $500,000 will be waived.

California

In response to two legal violations that drove up costs for patients, the California Department of Managed Health Care fined Anthem Blue Cross (ABC) $1.1 million in June 2022. The violations: not correctly applying office visits to more than 6,500 members’ deductibles and failing to mail explanation of benefits to more than 363,000 members. In addition to the fine, ABC has agreed to take corrective actions, so these issues do not occur again in the future and reimburse approximately $9.2 million to members who were impacted.

About the Author:


Matthew Dubnansky TMDG Healthcare Assurance and Risk ConsultingMatthew B. Dubnansky, CPA, CGMA | Partner
Matt leads our national healthcare assurance and risk consulting practice. He is a forward thinking leader who works with plan sponsors across North America to better manage and oversee their plan benefit administration. He is also a published author and speaks on various topics at industry leading conferences. Matt provides clarity to simplify an otherwise complex healthcare system, focus to concentrate resources on what matters most, and actionable insights to optimize health plan administration.