'Systemic failures' at Anthem have left $300M in unpaid claims, New Hampshire hospitals say

Hospitals across New Hampshire say Anthem's operations and overall performance in the state has left providers with $300 million in unprocessed claims and created "universal dissatisfaction" with the Elevance Health subsidiary. 

In an April report from the New Hampshire Hospital Association, hospitals describe "systemic failures" at Anthem BCBS (the state's largest commercial payer) that were first reported in early 2021. In response, the NHHA began conducting quarterly member surveys about the reported issues, and met with Anthem leaders regularly for more than a year in an effort to find solutions.

In total, 22 acute care hospitals in the state responded to the initial survey and six follow-up surveys that took place through January 2023. 

"Anthem’s leaders informed hospitals that long awaited fixes for many of Anthem’s broken system issues were in place and that as a result hospitals would see claims paying correctly and aged claims being adjudicated resulting in a reduction in AR," the report said. "As of the date of publication of this report, hospitals have not experienced a new and improved Anthem, in fact, they report that very little has changed."

Hospitals reported specific challenges when working to submit claims and receive payment through Anthem: 

  • In-network providers being unexpectedly dropped from provider directories, resulting in an incorrect out-of-network status across provider types and specialties and leading to major coverage and claims processing issues.

  • Misalignment of prior authorization instructions between Anthem and Carelon, the company's healthcare services division. "Because of this mismatch, Anthem incorrectly denies claims for multiple services that are submitted without an authorization even though Carelon instructed the provider that an authorization was not needed," the report said.

  • Unresolved technical issues with customer service and Availity, Anthem's online claims processing portal for providers. The report also noted millions of dollars in unresolved claims within Anthem's HART Grid, a system the payer uses to track and resolve claims that already went through the standard reconsideration process.

"Hospitals are seeking effective solutions to solving pervasive issues which will create a smoother experience for all parties and result in better working relationships, reduction in AR, and free up resources to focus on what matters most—patient care," the report concluded.

In a statement shared with Becker's, Anthem BCBS in New Hampshire said that over the last year, the company has processed 92 percent of New Hampshire claims within 14 days, and 98 percent within 30 days. 

“The hospital association’s report contains a number of inaccuracies and exaggerations, the most egregious being the grossly inflated outstanding accounts receivable number, which is based on billed charges and does not reflect the amount that is actually paid to the hospitals after applying the discounts that we negotiate on behalf of our customers, significantly reducing the amount reflected in the report," an Anthem spokesperson said. 

"In addition, while the report acknowledges that just under 50 percent of the outstanding amount is within 30 days, the report fails to acknowledge that a large portion of what remains over 30 days are claims that may have already been appropriately denied but are being disputed. It is commonplace to have some claims outstanding and even disputed after adjudication given the volume of daily submissions, and the review required to ensure claims are coded, billed, and paid correctly. In total, Anthem paid $1.28 billion in claims payments to New Hampshire hospitals in the last 12 months, the vast majority within 30 days. We strive to reduce inventories as they occur and remain committed to working directly with our care providers and health systems in resolving any challenges that may exist. We have regular calls with the hospitals to review issues when they arise, and these calls lead to constructive conversations. We will continue to partner with the hospitals in our state to improve the health of those we mutually serve. Unfortunately, the association’s report is not reflective of the partnership we have with our care providers.”




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