State hits Anthem with whopping fine for insurance violations – Georgia Health News

By Rebecca Grapevine and Andy Miller

The state insurance department has levied a $5 million fine against health insurer Anthem Blue Cross Blue Shield, the largest such penalty in the agency’s history, for violations of state law involving medical providers and consumers.

Insurance Commissioner John King, at a Tuesday news conference at the State Capitol, cited numerous complaints in taking the agency action.

King speaking at press conference Tuesday

The Georgia insurance department was “inundated with complaints about Anthem from individuals, from doctors, hospitals and others, from all corners and across Georgia,” King said.

Among the complaints was that Anthem’s directories have listed some health care providers as being network providers when in fact they were not participating in those insurance plans.  Such erroneous listings can mislead patients who pick a health plan based on whether a certain doctor or hospital is in that network.

Philip Mattera, director of the Corporate Research Project at Good Jobs First, a corporate and government accountability organization, said that the $5 million fine is among the top 1 percent of state government penalties against insurance companies that his organization has tracked.

In February 2020, the state insurance department issued warning letters to five insurers, including Anthem, stating that the agency found providers listed as being in-network although they were not actually participating in those networks. The letters were obtained by GHN through an Open Records Request.

In the Anthem case, providers said the insurer failed to pay them promptly, state officials said Tuesday. The company also negotiated contracts with medical practices and then failed to load those providers into its system, leaving patients and doctors out in the cold, King said.

“There have been instances when doctors and hospitals had to lay off staff” due to Anthem payment delays, King said.

An Anthem spokeswoman, Denise Ward, said Tuesday that the company “­strives to process and pay claims as quickly and efficiently as possible in accordance with provider agreements and applicable state laws and regulations.”

She said the Georgia insurance department focused on a provider database system implemented nearly seven years ago that is no longer in use.

“As the department is aware, we worked diligently to address these challenges,” Ward said. “We have since migrated to a new platform with the goal of improving accuracy and transparency.”

The investigation found around 78,000 separate violations, state officials said. They involve Medicare, employer health plans, and state insurance exchange plans.

“A clear pattern has emerged,” King said. “As I traveled across Georgia, this became a running theme.”

The consent decree also requires Anthem to take corrective actions to prevent future violations and respond to complaints in a timely manner.

“We will hold insurers accountable when their actions are unfairly impacting Georgians,” King said.

The $5 million will go to the state’s general fund, said King, a Republican. King has held the state insurance post as an appointee since 2019, due to the previously elected commissioner’s arrest and subsequent conviction on fraud charges. King is running for election to the post.

Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University, said that many problems identified in the Georgia investigation “result in the consumer holding the bag financially – there’s nothing in there to make them whole.”

“This is the insurance department doing its job,” said Corlette of the state fines. “It looks like [Anthem] has some work to do in terms of cleaning up its act.”

Earlier this month, Anthem announced that it is changing its name to Elevance Health.

Some state legislators stood behind King and said that they had heard similar complaints from their constituents.

Laura Colbert, executive director of advocacy group Georgians for a Healthy Future, praised the state action. “For our health care system to work as intended, patients, providers, and insurance companies each have to hold up their respective ends of the bargain,” Colbert said. “When Georgians paid their health insurance premiums each month, they did their part. Blue Cross Blue Shield failed to do the same when they were slow to address members’ complaints and made it difficult for members to access health care by sharing inaccurate information about which doctors were in-network.”

Northside Hospital Atlanta

Meanwhile, Anthem is still locked in a contract dispute with the Atlanta-based Northside Hospital system.

A Fulton County judge has extended a reprieve in the dispute between Northside Hospital and Anthem until April 15, delaying for a second time the need for thousands of patients to switch doctors.

Northside patients who have Anthem insurance have been caught in the middle of the battle between the insurer and the hospital system for months.

King said that as a Georgia consumer, he is concerned about the contract standoff, but added that his department does not have the authority to force a resolution.