A federal arbitrator has ordered Indianapolis-based Anthem to pay $4.5 million to a group of 11 Indiana hospitals, according to the Indianapolis Business Journal.
Anthem says it has complied with the order, but the hospitals say they could ask for more.
The case involved contracts between Anthem and the hospitals to cover Medicaid patients. The payer's reimbursement system identified emergency room claims from the hospitals and matched them with approved diagnosis codes. For claims that didn't align with approved codes, Anthem charged a triage fee between $50 and $70 and asked the provider to submit additional patient records to avoid denial.
The arbitrator ruled that Anthem must stop using their list of diagnostic codes to downgrade or deny the hospitals' claims.
The hospitals claimed that Anthem's triage fee strategy negatively impacted 60 to 70 percent of the thousands of ER claims collectively submitted between January 2017 to May 2020. The hospitals said the strategy was illegal and a breach of contract because they are required to stabilize all patients who request emergency services, according to the IBJ.
The hospitals now say they could claim at least another $12 million from Anthem for thousands of additional claims that the payer allegedly downgraded and did not pay in full. The disputed claims are also still increasing.
The arbitrator's ruling also orders Anthem to pay for all claims that were downgraded, though a monetary amount was not provided. Anthem has not said whether it will pay additional damages, according to the IBJ.