qotd: Anthem Blue Cross punishing patients and providers for their own error

California Medical Association
CMA Alert
June 30,2014
Error on Anthem ID cards results in claim denials

In late March, the California Medical Association (CMA) began receiving
complaints from physicians in San Diego, Orange and Bay Area counties
about denials from Anthem Blue Cross. Practices reported that patients
presented to their offices with Anthem ID cards that indicated they had
a Covered California/mirror PPO product and subsequent eligibility
verification also indicated the patient had a PPO product.

However, Anthem later denied the claims stating the services were not
covered under the patients' benefit plans because they received services
from out-of-network providers.

CMA escalated the issue to Anthem and learned that while the Anthem ID
card and eligibility verification indicated these patients had purchased
PPO products, it was a mistake. These patients had actually purchased
EPO products, with no out-of-network benefits.

While Anthem is offering a PPO product for their Covered
California/mirror patients in most counties, they are only offering an
EPO product in San Francisco, Los Angeles, Orange and San Diego
counties. The Anthem EPO product does not provide any benefits if
patients receive services from out-of-network physicians/facilities.

At CMA's urging, Anthem corrected the affected patient ID cards and
reissued new cards to EPO patients in May. Anthem also confirmed they
have updated the information that displays when physicians verify
eligibility to accurately reflect the correct product type.

CMA requested that Anthem automatically reprocess affected claims at the
PPO rates, the product the ID card and eligibility information
reflected, but Anthem was unwilling to do so. Instead they are requiring
patients to appeal each individual claim to Anthem.

http://www.cmanet.org/cma-alert/archives/2014/june-30-2014

****


Comment by Don McCanne

Anthem Blue Cross made a mistake in that they provided ID cards and
eligibility verification for their EPO (exclusive provider) patients
that indicated they were PPO (preferred provider) patients. PPO patients
can obtain some care out-of-network but with reduced benefits. EPO
patients are not eligible for any benefits out-of-network.

The California Medical Association has requested that Anthem Blue Cross
reprocess those claims based on the PPO status that they had verified.
Anthem has refused to do so, insisting that each claim be appealed
individually. For an industry noted for administrative excesses and
placing an administrative burden on health care providers, they are
carrying it to an extreme wherein they are requiring much more
administrative excesses to rectify their own error - punishing patients
and providers for their own mistake.

How can this industry be so crass? Yet this industry, which should be
placing patient service above all else, places its own business
interests first. Such an insensitive response would never take place if
our health care financing system were to be managed by our own public
administrators. EPOs wouldn't even exist. It's time to replace the
private insurers with a publicly-admiinistered single payer system.