The Georgia DOI Fined Anthem $5MM for Improper Claims Practices
Making history as the biggest fine ever issued against an insurance carrier in Georgia, Anthem Blue Cross Blue Shield must pay $5 million due to thousands of consumer violations against Georgian policyholders. A state examination revealed numerous improper claims practices including, but not limited to, improper claim settlement practices and inaccurate provider directories. In practice, this means a policyholder may have selected a provider believing it to be in-network when in fact the provider was not, which led to much larger bills.
Demonstrating a history of nonresponsiveness to consumer’s complaints, Anthem is now mandated to create a new process for providing customer service and paying claims in a timely manner. If they do not comply, Anthem could be hit with even more penalties.
The fine and corrective action agreement was driven by what appears to be an admitted lack of care, at a minimum, by Anthem as it adjudicated claims submitted to providers by Anthem for people in both Anthem’s fully insured plans and self-funded plans for which Anthem acted as the claims administrator.
As a result of Anthem’s lack of care, claims were processed and adjudicated improperly, which Anthem concedes.
It is unlikely that the lack of care exercised by Anthem as it adjudicated the claims were exclusively to the detriment of the providers who may have been misclassified as the Georgia Department of Insurance determined. The apparent misclassification of providers may have resulted in overpayment of the claims by self-funded plans. Based on the public materials from the Georgia DOI, it is not clear whether that was within the scope of the investigation they conducted.
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