A report from the Office of the New York State Comptroller published Jan. 6 found Anthem Blue Cross either did not recover or remit over $19.3 million in hospital claim overpayments and relied on incorrect time periods to evaluate the recoverability of about $15.1 million in overpayments.
Following the findings, Anthem remitted $7.3 million but nearly $12 million still needs to be addressed.
The audit aimed to evaluate whether Anthem “effectively administered the recovery process and remitted all recoveries” the state’s Department of Civil Service was owed for administering the state’s employee health plan. The audit included claims from January 2019 through May 2024, along with an expansion back to January 2018 for claims affected by contract recovery time frame limits. New York’s Department of Civil Service contracts with Anthem on the Empire Plan — specifically its hospital program, which covers services by hospitals, skilled nursing facilities and hospices — for local employees.
The report also said Anthem’s hospital contracting negotiations hindered its ability to comprehensively evaluate $55.8 million in payments that the insurer originally found that part of the payment was made incorrectly.
During the audit period, Anthem paid over $18.6 billion for Empire Plan member services.
“The audit identified opportunities to further strengthen recovery processes, and we have already taken action,” an Anthem statement shared with Becker’s Jan. 7 said. “As of the end of the third quarter, we have recovered $8.4 million in overpayments on behalf of the state employees’ health plan — an amount that exceeds what is reflected in the report.”
