Anthem likely to defy order to pay outstanding claims

California state regulators ordered Anthem Blue Cross Blue Shield on Thursday to pay providers for outstanding claims owed during the last four years. However, Anthem is pushing back and might not comply with the order.

The California Department of Managed Healthcare (DMHC) identified errors in claims that Anthem processed since 2007, prompting it to demand the state's largest for-profit insurer pay the outstanding amounts it owes doctors and hospitals, reported the Sacramento Business Journal.

Anthem, though, says it already settled the outstanding claims with DMHC when it paid a $500,000 administrative fine as part of a settlement agreement last year. "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," said Anthem spokesperson Darrell Ng.  

The settlement was a result of DMHC's claims audits in 2008 after providers complained of insurers' late and inaccurate payments and inappropriate claims denials. DMHC ordered several insurers, including Anthem, to pay providers, improve their claims processes, sign settlement agreements and pay administrative fines. All insurers involved have begun paying the outstanding claims except Anthem, noted the SBJ.

Despite paying the $500,000 fine, DMHC spokesperson Rodger Butler said Anthem "did not address nor resolve corrective actions required by the audit process including the remediation of claims, repaying medical providers for claims violations discovered by the audits," according to the Associated Press.

DMHC has given Anthem 30 days to submit a plan for corrective action. Anthem said it would need to review 2.6 million claims to comply.

To learn more:
- read the DMHC press release and Anthem order (.pdf)
- see the Sacramento Business Journal article
- check out the Associated Press article

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