Anthem Industry Concerns

April 20, 2022

Anthem is making news in the healthcare industry, and it’s not the good kind. Recently there have been some healthcare articles focused on issues providers are facing with Anthem.  One such article addresses some concerns with Anthem’s update to its claims processing system and issues with their artificial intelligence algorithms being set to automatically deny legitimate and medically necessary claims.  Some providers have reported experiencing contract negotiation delays on the side of the carrier. Other providers are experiencing overall reimbursement delays.  

Anthem of Georgia has Open Access POS, Pathway and HMO plans that require physicians to send non-stat lab cases to LabCorp. They will pay if billed with a place of service of inpatient or emergency room (IP or ER) but, will deny outpatient claims.  Most of the time they deny payment and attempt to apply a full contract adjustment.  A sample denial could be pre-certification/authorization not received. Hospital based surgical pathology codes should not be considered a part of this requirement, as pathologists are responsible for the specimens that go through the hospital lab, who is getting paid for their component of the procedure.  In this scenario, it also seems that Anthem could be running the claims through an automated system/algorithm and denying based off the patient’s place of service and not considering that it’s surgical pathology codes being billed, or that the hospital is being paid for their portion.  When seen, these denials are being escalated to the provider relations level so Anthem can correct their system to not deny the outpatient pathology billing and reprocess claims for payment.      

In Maine, the state insurance commissioner is currently investigating Anthem’s conduct.  Due to what the state of Georgia considers violations of state laws and agency rules and regulations, the commissioner there recently fined Anthem $5 million.  The issues included violations of the Prompt Pay Act, improper claims settlement practices, inaccurate provider directories, failure to reply to consumer complaints timely and significant delays in loading provider contracts.  Wisconsin’s insurance commissioner has been involved in assisting providers experiencing erroneous claim denials from Anthem.  New Hampshire is working with Anthem to resolve payment delays and Ohio’s insurance commissioner has encouraged any providers experiencing issues with Anthem to come forward.  

The much concerning trends of automatic, erroneous denials for medically necessary claims, stalls in contract negotiations and delays in claim payments, coupled with their recent update in timely filing to a mere 90 days is causing much concern across the industry. 

APS has a robust Denial Management team that continues to monitor and work denials for all of our clients across all payers.  We will continue to monitor these concerning trends from Anthem and work through any that may arise.