According to hospital officials in multiple states, Anthem Blue Cross is behind on billions of dollars in payments to hospitals because of new reimbursement rules, computer problems, and mishandled claims—this according to an article in Kaiser Health News published on October 6, 2021 available here. An Anthem spokesperson was quoted, saying “[w]e recognize there have been some challenges” and “[w]e apologize for any delays or inconvenience this may have caused.” Hospitals cite a variety of causes to the payment delays and denials, including “new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves—not support staffers—speak to insurance gatekeepers.”

This is nothing new to King & Spalding’s healthcare partner in Los Angeles, Daron Tooch, who has represented providers for almost three decades to recover underpayments from insurers like Anthem. Mr. Tooch is representing a number of hospitals that are owed tens of millions of dollars from Anthem for a variety of reasons, including:

• Denials for outpatient infusion medications for hospital refusing to comply with Anthem’s Specialty Pharmacy or “White-Bagging” policy;

• Line-item denials of charges on claims on the grounds that such charges are “routine” or included in other charges;

• Improper downcoding of DRGs or CPT codes;

• Denials for lack of authorization for services that do not need prior authorization or for which authorization was received;

• Denials of claims as the financial responsibility of IPAs or other payors;

• Claims that are priced incorrectly;

• Delays in processing and payment of claims; and

• Out-of-network payments that are not reasonable value.

Another example was discussed in the Kaiser Health News article regarding VCU Health, a healthcare system in Virginia. VCU Health says Anthem owes it $385 million dollars, and that 40% of those claims are more than 90 days old.

Anthem’s regulatory filings reflect the issues about which the providers are complaining and that the situation may be getting worse because of the COVID-19 pandemic. The Kaiser Health News article reports that on June 30, 2019, 43% of Anthem’s medical bills for that quarter were unpaid. Two years later, that figure rose to 53%—representing a difference of $2.5 billion. The Kaiser Health News article further reports that in 2020, Anthem profits were $4.6 billion, and in just the first half of 2021 that figure was $3.5 billion. In other words, Anthem is reaping large profits while failing to accurately and timely pay hospitals.