Health care providers are considering what actions to take after the state Department of Managed Health Care last week ordered Anthem Blue Cross to stop seeking millions of dollars in reimbursements for old health care claims that the insurer believes were overpaid, the Sacramento Business Journal reports (Robertson, Sacramento Business Journal, 7/20).
State law allows health insurers to seek reimbursements for overpaid medical claims within one year of the payment date.
If insurers seek reimbursement for claims that are older than one year, they must demonstrate that the health care providers engaged in fraud or misrepresentation.
Between 2008 and 2011, Anthem sought to collect reimbursements from 535 health care providers for overpayments on claims that were more than one year old, according to DMHC. Anthem alleged that the providers had improperly coded the claims.
According to the DMHC order, the agency conducted an investigation and found that the insurer could provide no evidence of fraud or misrepresentation by the health care providers (California Healthline, 7/18).
Possible Next Steps for Health Care Providers
The California Medical Association -- which originally asked DMHC to investigate Anthem's actions -- is pushing for the insurer to repay the money it collected for old claims.
Molly Weedn -- spokesperson for the association -- said CMA will be in talks with state officials about helping health care providers recoup the payments.
DMHC is examining the issue and is considering possible solutions, according to spokesperson Marta Green.
Department officials said that if a health care provider receives or has received a notice from Anthem or any insurer seeking recoupment of claims that are more than one year old, the provider should file an appeal with the insurer. If the appeal is unsuccessful, the provider should file a complaint with DMHC, the agency said.
Response From Anthem
Darrel Ng -- Anthem spokesperson -- in a statement said that the insurer sought reimbursement for overpayments that resulted from double billing.
He said, "The issue is about Anthem Blue Cross' efforts to keep health care affordable" (Sacramento Business Journal, 7/20).