On Dec. 1, ISMA President David Welsh, M.D., American Health Network’s Don Stumpp, representing IMGMA, and key ISMA staff met with Anthem to discuss the problems that began late last year.

Representing Anthem were VP of Health Services David Lee, M.D.; RVP Network Contracting and Education Linda Barrabee, Managing Legal Mark Kohler, and VP of Commercial Service OP Laureen McCrae.

Anthem officials explained that a multi-phase computer changeover in October 2007 negatively impacted providers in five states, including Indiana. The insurer and its customer service staff quickly became overwhelmed and other problems subsequently occurred. To date, Anthem has not widely initiated any communication to physicians about these issues.

However, Anthem conducted self-audits to identify problems and implement solutions. Officials believe remedies are working and things are improving. They meet every other week to update the IDOI for its investigation.

Some specific issues
The ISMA presented issues identified by members, asked Anthem to explain what occurred and provide a status report on how things are being resolved. Here’s what Anthem said.

Customer Service – Response time is improving. Anthem confirmed an offshore vendor handles calls in Argentina and Puerto Rico for local business but not calls related to home plans. These plans have hired more staff and outside agencies; training is ongoing.

Claims denied as duplicate – Anthem experienced a software problem and turned off the clinical editing software that was causing a problem. The insurer said this issue was resolved at the end of October. Practices do NOT need to re-file claims. Anthem will honor the original filing date.

Missing attachments – An outside vendor Anthem hired for data entry had major quality issues. Claims were denied erroneously for missing documentation. This is now back on track; it was a performance issue, not a systems glitch.

Claims denied as out of network – An error occurred with two databases Anthem uses for provider and pricing information. This was a systems error mainly remedied in November; work will continue this month, which should correct 80-90 percent of the issues. Physicians who called about this problem had claims adjusted manually. The majority of claims should be corrected by the end of December. However, if you are an in-network provider but receive a denial or reduced pay as out of network, report it to Anthem Customer Service.

Fee schedule payment errors – These are part of the systems glitch of last October. Anthem stated these problems are being corrected and claims are being automatically re-processed. If you were paid incorrectly, contact Anthem Customer Service. If you are unsure of your fee schedule, call Customer Service or your contract representative and ask about particular CPT codes. Or check Anthem’s Web site.

The follow-up plan and your role
The ISMA plans to monitor Anthem’s progress and scheduled another meeting for January.

“We need the help of our physicians to keep us informed of any further problems with Anthem claims or to advise if there are delays in resolving past claims,” said ISMA President David Welsh, M.D.

Anthem leaders said they are paying interest on late payments and underpayments, according to state law. Indiana’s interest rate was 3 percent per day for 2007 and 5 percent per day for 2008. However, claims for patients in a non-Anthem state Blue Card program, for example GM workers under a Michigan plan, are not eligible for interest from Anthem.

Watch your reimbursements to identify appropriate interest payments. If interest is not paid, submit your example to the ISMA; call Julie Reed, ISMA legal counsel, if you have questions. Also notify the ISMA if your payment and service issues with Anthem have not yet been resolved (past or current claims).

Anthem may still be working on an issue you contacted them about, as part of their backlog. To check on the status of a past inquiry, call Anthem Customer Service.