Anthem refuses to repay claims

The Blues plan says it paid a fine to resolve mishandled claims. California regulators say the insurer also must pay doctors and hospitals.

By Emily Berry — Posted Jan. 31, 2012

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Physicians and hospitals who expected to receive a check from Anthem Blue Cross of California after a 2010 settlement over botched claims will have to keep waiting. Despite an order from state regulators, the Blues plan is refusing to pay what the state says the insurer owes doctors and hospitals.

The dispute stems from a 2008 audit by the Dept. of Managed Health Care, which regulates California's HMOs. The agency examined claims payment records from Anthem Blue Cross along with Blue Shield of California, Aetna, UnitedHealth Group, Health Net, Kaiser Foundation Health Plan and Cigna during the 18-month period starting in July 2007.

After completion of its audit in 2010, the DMHC fined all seven plans, totaling nearly $5 million. The department found that they had failed to promptly and correctly pay claims and resolve payment disputes. It also required the insurers to show what they will do to avoid further delays, and repay the money they owe hospitals and physicians. None of the plans admitted wrongdoing.

Anthem, a division of WellPoint, said it believed the matter was over when it paid its fine, but the DMHC says Anthem still needs to go back to the mishandled claims and make sure they're properly paid -- with interest. The DMHC also found that the insurer failed to show it had improved its claims processing to avoid repeating the problems uncovered in the audit.

In a Jan. 12 order, DMHC gave Anthem 30 days to identify the problem claims from the audit period and pay them correctly. It did not appear likely that Anthem would follow the order.

"While we acknowledge and respect the DMHC role in regulating health plans, Anthem Blue Cross and DMHC have already settled the matter in question in a November 2010 agreement that fully and completely settles all matters related to the department's report," spokesman Darrel Ng said in a statement. "Today's action seeks to reopen a matter in which Anthem Blue Cross has already paid a fine and taken steps to prevent future occurrences."

Ng wouldn't say whether the company will challenge the order formally. "We're examining our options," he wrote in an email.

The California Medical Assn. applauded the DMHC action and offered to help any physician looking to get fairly paid for care.

"We provide necessary care to our patients based on the assumption that the health plans will promptly and accurately reimburse us for services rendered," CMA President James T. Hay, MD, said in a statement. "Anthem Blue Cross' refusal to pay for a mistake on their end puts an undue burden on those of us who provide care."

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn