Corrections and Explanations: This article has been revised by Kaiser Health News to correct uncertainty. The anthem did not create its own network of possibilities.
Anthem Blue Cross, the country’s second-largest health insurance company, is lagging behind due to tough rules for repaying billions of dollars owed to hospitals and doctors, computer problems and misguided claims.
The anthem, like other major insurers, is using the COVID-19 crisis to launch a “ruthless” policy that harms patients and worsens the hospital’s financial situation, said Molly Smith, vice president of the American Hospitals Association Group.
“Everyone is confused,” he said. We can do it, ”he said.
Hospitals are also dealing with claims rejected by UnitedHealthcare, the largest health insurer for the emergency department, the AHA said.
Disputes between insurers and hospitals are nothing new. But this struggle puts more patients in the middle because they have to pay for unresolved claims. Hospitals say it is hurting their financial situation as many struggle with COVID-19 waves — even after the industry received tens of billions of dollars in emergency aid from the federal government.
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“We acknowledge that during the pandemic, there were some difficulties in expediting payments due to changes in claims handling and a‘ new set of dynamics, ’” Anthem spokesman Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health System, which runs a large teaching hospital in Richmond that is affiliated with the University of Virginia Commonwealth, said the anthem owes $ 385 million. According to VCU, more than 40% of claims are more than 90 days old.
For all hospitals in Virginia, the anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Health Association said in a June 23 letter to state regulators.
Delays in payments across the country are “creating an unbearable situation,” the American Hospitals Association said in a Sept. 9 letter to CEO Gale Bodro. “Patients face major barriers to accessing medical care; clinicians burn unnecessary administrative tasks; and the system is struggling to fund the personnel and materials needed to fight the coronavirus.
In an interview with KHN, AHA CEO Rick Pollack said complaints about the anthem ranged “from sea to bright sea, from New Hampshire to California.”
Significant delays in payments can be seen in the Anthem books. According to the regulations, on June 30, 2019, before the pandemic, 43% of the insurer’s medical payments for this quarter were not paid. Two years later, the figure rose to 53% – a difference of $ 2.5 billion.
Revenue from the anthem was $ 4.6 billion in 2020 and $ 3.5 billion in the first half of 2021.
“It’s a game they play.”
Alexis Turber, who lives near Seattle, was insured by Hymn in May when doctors received a $ 18,192 hospital bill for radiation therapy needed to treat her breast cancer.
According to Turber, the treatment was “experimental” and “medically unnecessary.” He spent most of the summer trying to pay the insurer – twenty phone calls, waiting for hours, sending a few emails, coping with stress and worries. Finally, a few months later, the lawsuit was settled.
“It’s very cruel. It’s a game they’re playing,” said Turber, 51, who was diagnosed with cancer in November. “It was impossible to try to get real help.”
Privacy rules prevent Hymn Thurber from commenting on the case, said Hymn spokesman Colin Manning.
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If insurers fail to pay medical bills on time, patients will suffer. They may first receive a notification that payment is expected or denied. The hospital can book for the treatment they think will be covered. Hospitals and doctors often sue uninsured patients.
Hospitals point to various anthem practices that contribute to delays or denials of payment, including new layers of documentation requirements, pre-approval barriers to routine procedures, and staff-insurance gatekeepers rather than doctors themselves talking requirements.
“It requires providers to literally leave the patient[’s] the anthem will be played next to the phone, ”the AHA said in a letter.
AHA officials say the anthem often prevents outpatient surgeries, specialized pharmacies and other services in the health care system from being registered within the network.
“Requiring patients to be treated outside the hospital stems from the Empire’s desire to increase the patient’s income, on the recommendation of the patient’s on-net physician,” the Greater New York Hospitals Association wrote in a letter in April. Empire Blue Cross belonging to the anthem.
In a recent letter to the AHA, anthem officials said the insurer’s amended rules were partly designed to control the overprices charged by hospitals for special medications and non-emergency surgery, screening and diagnostic treatments.
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The AHA said in its letter that serious problems with the anthem’s new claims management system arose a few months ago and “continue to improve significantly.”
The claims were lost on the anthem computers, and in some cases VCU Health had to print medical records and mail them to pay, VCU said in its letter. The decline in cash will result in “an unmanageable disruption that threatens to destabilize our financial situation,” VCU said.
The “surprisingly aggravating” response
United rejected a $ 31,557 claim for care of Emily Long after she was hit by a motorcycle in New York in June. He needed surgery to fix the broken cheekbone. United said there were no documents for “medical need” – an “extremely aggravating” response during the accident, Long said.
“Brooklyn Hospital, which treated Long, was paid according to plan and on time,” said Maria Gordon Schidlo, a spokeswoman for the United Nations. “The organization has the right to appeal the decision.”
United’s unpaid claims were 54 percent as of June 30, the same as the previous two years.
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When Erin Conlisk had trouble getting medical equipment for her elderly father this summer, United officials told him that the insurer’s authorization base had been down for weeks, said Conlis, who lives in California.
“In mid-July, there was a brief problem with our authorization process that was quickly resolved,” Gordon Shidlo said.
When asked by Wall Street analysts about backups of payments, Anthem executives said it partially reflected their decision to increase financial reserves in the wake of the health crisis.
“Indeed, there are a number of uncertainties surrounding this environment,” said John Gallina, the company’s chief financial officer, at a conference call in July. “We tried to be very careful and conservative in our approach.”
“Severe fear of speaking in writing”
During the pandemic, hospitals benefited from two unusual money infusions. They and other health care providers have received more than $ 100 billion through the 2020 CARES Act and the 2021 American Recovery Plan. Last year, United, Anthem and other insurers accelerated billions in hospital payments.
Federal payments have enriched many of the richest and most affluent systems, leaving poor hospitals and villages in a difficult position to serve low-income patients.
Hospital officials say these are the systems that have suffered the most from the insurer’s delay in payment. Federal aid funds have been “life-saving, but they don’t heal people in terms of the increased costs and lost revenue from the coronavirus experience,” Pollack said.
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Several health care systems declined to comment on payment delays or did not respond to reporter’s inquiries. AHA Smith said that among individual hospitals, “you may be afraid to talk about your biggest business partner.”
Alexis Turber was worried he might pay the $ 18,192 radiation bill himself, and he doesn’t believe Anthem Policy would do a better job of paying his anthem next time.
“It makes me not want to go to the doctor,” he said. “I’m afraid to get another mammogram because you can’t rely on it.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Together with policy analysis and survey, KHN is one of the three major operating programs of the KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides information on health issues to the country.