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Anthem: Self Funded- not covered under benefit plan question

  1. #1
    Default Anthem: Self Funded- not covered under benefit plan question
    Medical Coding Books
    Hi there,

    We are experiencing a problem with Anthem Self funded plans denying services performed by an AS using the remark that it is non-covered under the patients benefit plan. These services are listed under Anthem's approved AS services listing.

    We have been writing letters to the employers as well as the plan, requesting a copy of the patients benefit plan summary. We've had some success getting claims reprocessed and paid- simply by requesting this information. However, we have one local employer that is not cooperating. These balances are usually about $5,000 and we really hate to bill the patient for these services when we truly feel that they are not being processed correctly.

    We've considered using the DOL but have been instructed that we have no legal recourse thru them; only the patient does. Has anyone else encountered this and what have you done besides billing the patient? Any help is greatly appreciated.

    Thanks,
    Danielle

  2. #2
    Default Did you get prior auth for the services?
    Did you get prior auth for the services?

  3. #3
    Default
    Quote Originally Posted by daniellemiller View Post
    Hi there,

    We are experiencing a problem with Anthem Self funded plans denying services performed by an AS using the remark that it is non-covered under the patients benefit plan. These services are listed under Anthem's approved AS services listing.

    We have been writing letters to the employers as well as the plan, requesting a copy of the patients benefit plan summary. We've had some success getting claims reprocessed and paid- simply by requesting this information. However, we have one local employer that is not cooperating. These balances are usually about $5,000 and we really hate to bill the patient for these services when we truly feel that they are not being processed correctly.

    We've considered using the DOL but have been instructed that we have no legal recourse thru them; only the patient does. Has anyone else encountered this and what have you done besides billing the patient? Any help is greatly appreciated.

    Thanks,
    Danielle
    Self-funded plans can get away with a lot, but they can't do whatever they want. For instance, they can't deny your claim without providing a written disclosure of the rationale used in the denial, upon your request. Who told you that you can't file a complaint with the DOL? Anthem? The reason I ask, is that 1) you're filing claims on behalf of the patient, so although the legal recourse would benefit you in the long-run, you'd technically be filing a complaint on the patient's behalf, as well - and 2) If they are simply refusing to give you written disclosure of the specific criteria that led to the denial, you as a provider should be able to file a complaint under ERISA, because it's screwing with your revenue. If the DOL told you that the patient is the only one who can complain, let the patient know what's going on, and get their permission in writing to file a complaint on their behalf. (For $5000, I think I'd sign a waiver, but that's just me...)
    You may also try complaining to the state attorney general and/or department of insurance - particularly if you had pre-authorization, or if everything you have in writing from Anthem indicates that this should be paid. Their activities could be illegal under trade laws.

  4. #4
    Default
    See: http://familiesusa.org/issues/privat...aoverview.html

    Hope that helps - definitely check your state's laws. Good luck!

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