Anthem denying in-network claims

Hi, I've posted here previously about my issues where my Colorado Anthem plan Network issues. My employer allowed me to change my plan back to the one I had when I had surgery. So that change has happened. Note that our plans start over 7/1.

I thought changing back to my old plan would solve my issues. I'm just trying to recover from surgery and have only been to 2 physical therapy appointments before I had issues with my Anthem plan (that were resolved by switching back to my old Anthem plan). After a 2 week gap, I got scheduled in a different clinic for physical therapy. I've been to this clinic before – they are in-network on all the Anthem plans I could have chosen from. The last time I went to then was 2023.

They called me today to say all of 2024, they have been having issues with my specific Anthem plan. They are in-network but when claims are sent in, Anthem denies them. Not for being out of network, but saying something about them being in the wrong "tier". This clinic is in a physical location where they get a lot of patients with my plan and it has been happening with all of them, just in 2024.

They told me other clinics near them are having the same issue (these are all stand-alone clinics). They are to the point where they are essentially not wanting to go through insurance on my plan. They are willing to only charge me $70 when my copay is $30 to not go through insurence. Their normal self-pay is over $100.

I also have a colleague who is on my same plan who lives across the state from me, and having the same issue with her physical therapy clinic. So this isn't just a problem with the one I am trying to go to. I can't go back to the physical therapists at my surgeons office because they are fully booked until the end of August and that would essentially be a 5 week break without physical therapy after an orthopedic surgery. Somehow my surgeons office can file physical therapy claims and not have an issue with Anthem (at least that I am aware of currently).

Anyone have advice on how I can:

1.) Fight with Anthem to make them cover my in-network physical therapy appointments

2.) Give feedback and advocate with my Employer to fight with Anthem that our plans need to be better… We are public service employees and part of a group where smaller colleges/universities buy in to get "better" health insurance coverage. This year in particular, the Anthem plans are awful. I need specific language to use to advocate because the problem I described above could potentially impact thousands of people in my state. It's not just a "me" problem

3.) What are tiers or what are these other mysterious reasons Anthem or Carelon would mess this up behind the scenes? Do I have hope in appealing on my side?

submitted by /u/squatsandthoughts
[comments]