Anthem ordered to pay $4.5M to Indiana hospitals over ER billing issues
A federal arbitrator ordered Anthem to pay $4.5 million to a group of 11 Indiana hospitals. Anthem said it complied with the order, but the hospitals said they could ask for at least $12 million more. 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.
Appeals court revives tribe’s lawsuit against BCBS of Michigan
A federal appellate court revived the Saginaw Chippewa Indian Tribe’s lawsuit against Blue Cross Blue Shield of Michigan that alleges the payer failed to fulfill its fiduciary duties in administering tribal health insurance, costing the tribe millions of dollars.
Anthem sued for alleged ‘inconsistent’ claims processing
An Idaho woman and her spouse filed a lawsuit against Anthem April 13 for allegedly violating the Employee Retirement Income Security Act by improperly processing their medical claims.
In 2018, the lawsuit claimed the payer’s “arbitrary and opaque claims administration procedures began to interfere with the plaintiff’s ongoing and medically necessary treatment.”
In 2020, the plaintiffs filed a claim with the Labor Department’s Employee Benefits Security Administration, which issued four demand letters to Anthem. The letters “identified dozens of claims … that had been processed incorrectly.” Anthem responded to the letters and reversed its decision on some of the prior claims decisions, but not all, leading to the lawsuit.
Two U of Southern California centers sue L.A. Care to obtain quality-of-care records
Two University of Southern California centers sued L.A. Care for the full release of quality-of-care scorecards under the California Public Records Act. The centers claimed they have sought the release of the scorecards through public record requests, but L.A. Care has refused to release unredacted scorecards that show how contracted providers perform.
Anthem sued over behavioral health benefits denial
An Arizona man sued Anthem over the denial of behavioral health benefits for his daughter. The daughter was born with congenital heart defects, which led to later complications throughout adolescence. She was eventually admitted to a residential treatment facility for mental, emotional and behavioral treatments. The father submitted claims for her treatment, but Anthem denied the claims as not medically necessary. The father alleges Anthem violated the Employee Retirement Income Security Act and the Mental Health Parity and Addiction Equity Act.
