The payer is being sued by members of employee-sponsored plans offered by subsidiaries Anthem Health Plans of Maine, Anthem Health Plans of New Hampshire and Empire Healthchoice Assurance. The plaintiffs accuse the payer of adopting mental health coverage criteria that are “far more restricted” than “generally accepted standards” after being denied residential psychiatric treatment, according to the initial lawsuit filed April 29, 2020.
The members claim that Anthem’s definition of medical necessity for some psychiatric treatments lacked sources that “specifically reflect generally accepted standards of medical practice for patient placement selection.” The initial lawsuit claims that Anthem has “tremendous financial incentives to artificially suppress behavioral health costs by restricting coverage for treatment of chronic behavioral health conditions.”
Plaintiffs are seeking to make the complaint a class action lawsuit.
Anthem contested the claims, arguing in court that its guidelines was a business decision, not a breach of its fiduciary duty.
The judge denied the motion, which means that Anthem will continue to face the accusations in court.
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