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After nearly 22 months of helping physician members resolve claims processing and payment delays caused by a flawed computer system migration, the ISMA has filed a national compliance dispute against Anthem Blue Cross and Blue Shield.
“The recent dispute was filed under the Wellpoint/Anthem Settlement Agreement of 2005, the result of a class action lawsuit that set up a complaint process to resolve violations – like those experienced by ISMA members,” explained Julie Reed, ISMA’s legal counsel. The ISMA is not filing a lawsuit.
Here are the main points of the compliance dispute filed July 9:
- Claims Processing and Payment – Anthem has failed to properly and timely process and pay claims to numerous physician practices, without payment of interest and resulting in inappropriate recoupments or denials. Claims are not being adjudicated properly. Electronic mechanisms to submit claims, verify eligibility and check status of claims have not worked properly. Anthem has routinely required practices to resubmit claims. Patient eligibility information has been inaccurate.
- Customer Service and Responsiveness – Anthem has failed to invest sufficient resources to improve the speed, accuracy and efficiency of responses to physician inquiries and concerns.
- Communication – Despite knowledge of its problems, Anthem chose not to communicate them to physicians and sometimes provided false information.
- Systems Improvements – Anthem has failed to successfully improve efficiency of the claims adjudication process, improve Internet functionality, reduce claim resubmissions, and improve accuracy of plan member eligibility information.
In the beginning
Problems surfaced following the computer database migration or integration Anthem initiated in October 2007 for claims in its BlueCard program. This migration, affecting Indiana, Ohio, Missouri, Kentucky and Wisconsin, had far-reaching effects.
“The ISMA began receiving calls from members in late 2007 and early 2008 about Anthem claims processing problems, but no patterns were evident,” said Reed. “However, the ISMA staff began contacting physician practices and reviewed complaints filed with the Indiana Department of Insurance.”
That research revealed numerous practices having problems. Additionally, practices were unable to obtain information or effective assistance through their Anthem provider relations representatives or customer service.
Offices reported long telephone wait times, multiple inquiries and appeals, phone messages that went unanswered, and claim denials for insufficient information when it had been provided.
Patients were affected by delayed or improperly processed claims, including Explanation of Benefit forms incorrectly showing the patient owed money. Patient co-pays and deductibles were often incorrect.
Reed noted, “Our physician members told us this strained patient/physician relationships when patients were led to believe their doctors improperly billed the claims or failed to submit information necessary to process the claims.”
The ISMA sent a letter in May 2008 encouraging the Indiana Department of Insurance (IDOI) to enforce the prompt pay law and also met with IDOI officials.
One practice’s experience
with Anthem |
One Indiana medical office detailed the following experiences to get Anthem to process one claim:
- 16 different telephone and written communications
- 10 different plan representatives contacted
- 2 records submissions
- 5 different assigned reference numbers
- 15-month time period
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| To learn more… |
Read more about the ISMA’s compliance dispute with Anthem on the ISMA Web site here.
To understand more about the 2005 Wellpoint/Anthem Settlement Agreement, see here and here. |
Communication with Anthem
The ISMA contacted Anthem to help
practices with:
- Payment delays
- One line item/unit being paid on multiple line item/unit claims
- In-network physicians improperly characterized as out of network
- Fee schedule and co-payment errors
- Customer service failures
- Improper denials and recoupments
After the unsuccessful systems migration, Anthem self-reported the problems to its investors and the IDOI in early 2008. The insurer's meetings with the IDOI are reportedly ongoing. However, Anthem officials chose not to communicate with doctors, even when the ISMA repeatedly asked them to do so.
The ISMA had several meetings with Anthem where the insurer provided a host of timelines for resolution of the problems – which only continued.
Current status
“The ISMA is still receiving complaints indicating a number of issues remain unresolved and new problems have now appeared,” said Reed. “It’s time for all of this to come to an end.”
The ISMA initiated the compliance dispute on behalf of all Indiana physicians to help practices with outstanding claims finally have them processed correctly. The ISMA also hopes this will prompt an examination of what actually happened to ensure that it never happens again.
Since it was filed July 9, the compliance dispute has been forwarded to a third-party mediator for resolution. At least two large Indiana medical practices have also filed compliance disputes.
Read future ISMA Reports for updates on this issue.
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