Doctors in Indiana and Ohio want action on claims delays

The Indiana State Medical Assn. is asking state regulators to investigate major delays in claims payments and problems with other basic functions at WellPoint subsidiary Anthem.

The request in May follows a similar request by the Ohio State Medical Assn. The OSMA filed its complaint with the Ohio insurance department in October 2008. Doctors in both states have been reporting major difficulties dealing with Anthem since late 2007.

WellPoint hasn't denied the problems. Investors worried that the claims backlog impairs the company's ability to predict medical costs and set corresponding premium rates, and executives have tried to reassure them that the problem is under control.

Doctors have reported delays of several months in claims payments from Anthem. They also have complained of payment errors, such as paying patients directly for care because the insurer's system misidentified the physician as out-of-network, paid the wrong physician or denied unpaid claims as duplicates.

Beyond those problems, doctors reported excessive wait times for customer service that made it difficult or impossible to get the other issues addressed.

Anthem spokeswoman Kim Ashley said the problems were caused by the adoption of a new system to process claims under the BlueCard network, which allows members of a Blues plan in one state to use the physician network for another state's Blues plan.

"We've implemented an aggressive plan to return our service to normal on this particular claims system," she wrote in an e-mailed statement. "During the first months of 2009 we made significant progress on all fronts."

She said a company audit earlier this year found that 96% of newly submitted claims processed through the BlueCard system are processed and paid within 30 days of receipt.

But medical societies say the problems persist.

"The information they're giving us is a constantly moving target in terms of when they will have their computer systems solved," said Mike Rinebold, director of government relations for the ISMA.

"In January they said it will be March, then we were told it will be later," he said.

Anthem told medical societies in Indiana and Ohio in April that it had fixed the problems, but both associations did follow-up surveys of their members and concluded that was not the case.

In May, ISMA put together a 100-page book of complaints based on survey responses and shared it with the state's insurance commissioner.

"We are now in constant communication with the Dept. of Insurance as to what their next steps might be," Rinebold said.

OSMA spokesman Jason Koma said no word has come from the Ohio Dept. of Insurance about its next steps.

Ohio's prompt-pay law requires insurers to pay clean claims within 30 days unless additional documentation is required. Indiana's law requires electronic claims to be paid within 15 days and paper claims within 45 days.

Under its class-action settlement reached in 2005, WellPoint is required to pay clean claims within 15 days for electronic claims and 30 days for paper. That agreement expires July 15.