Insurer under fire for millions in unpaid claims

Anthem has captured the attention of multiple hospitals and health systems across the U.S. as allegations of underpayment and inappropriate denials accumulate.

The insurer has been forced to pay millions already and continues to face off with providers.

Anthem is facing allegations of $70 million in unpaid claims from Portland-based MaineHealth. The health system said earlier this year that its flagship hospital, Maine Medical Center, would no longer contract with the insurer after its contract expires next year. Jeffrey Barkin, MD, president of the Maine Medical Association, said other providers in the state are leaving Anthem for the same reason.

In Georgia, the state insurance commissioner fined Anthem Blue Cross Blue Shield $5 million in March for failing to pay in a timely manner, delays in loading provider contracts and inaccurate provider directories.

VCU Health in Richmond, Va., said last year that 40 percent of its claims with Anthem were more than 90 days old and the insurer owed $385 million, according to the Richmond Times-Dispatch. The Virginia Hospital and Healthcare Association said Anthem has hundreds of millions of dollars in late and unpaid claims to hospitals across the state.

Eleven Indiana hospitals have also had trouble with Anthem. The hospitals alleged Anthem’s reimbursement system added a $50 triage fee and asked for additional patient records to avoid denial for 60 to 70 percent of thousands of emergency room claims from 2017-20. The hospitals alleged the strategy breached their contract with Anthem because hospitals are required to stabilize all patients requesting emergency services. A federal arbiter recently ordered Anthem to pay $4.5 million to the hospitals and said the insurer cannot use its list of diagnostic codes to downgrade or deny claims.

The Indiana hospitals are still counting the denied claims and said they are owed $12 million from Anthem due to downgraded claims.

The American Hospital Association accused Anthem of asking for prior authorizations for routine surgeries as roadblocks to patient care in a letter sent to the insurer last year. In 2021, 53 percent of Anthem’s medical bills for the second quarter were unpaid, amounting to $2.5 billion, according to the Times-Dispatch report.

Justice Department adds CEO to $120M Medicare fraud case

The Justice Department has intervened in a whistleblower lawsuit accusing former executives of San Antonio-based Merida Health Care Group of violating the False Claims Act, according to Law360

The Justice Department is intervening in the action, which dates back to 2015, alleging the former executives submitted more than $120 million in false claims to Medicare for medically unnecessary home health services and hospice care. The Justice Department is also adding Merida Health Group’s former CEO Henry McInnis to the complaint, according to the report. 

The Justice Department alleges Mr. McInnis and Rodney Mesquias, the former owner of Merida Health Care Group, violated the False Claims Act, and the government is also seeking damages under the common law and equitable theories of fraud and payment by mistake, according to court documents filed April 7 in the U.S. District Court for the Southern District of Texas. 

Mr. McInnis was sentenced to 15 years in prison in February 2021 for his role in a healthcare fraud and money laundering scheme. Mr. Mesquias was sentenced to 20 years in prison in late 2020. 

Florida physician convicted of $110M fraud

Report from the Department of Justice Fraud & Abuse Control for 2017 sheds  light upon the importance of compliance - The Coding Network

A Florida physician was convicted Feb. 10 for his role in a healthcare fraud scheme that involved billing health insurance companies for $110 million in medically unnecessary services, according to the Justice Department

Mark Agresti, MD, of Palm Beach, Fla., unlawfully billed insurers for $110 million of drug testing services that were medically unnecessary. The patients who received the unnecessary drug tests were residents of Good Decisions Sober Living in West Palm Beach. Dr. Agresti was the medical director of the facility, according to the Justice Department. 

“Patients at GDSL were required to submit to excessive, medically unnecessary urine drug tests as a condition of residency approximately three or four times per week,” the Justice Department said. “These [urinalysis] drug tests cost as much as $6,000 to $9,000 per test.”

According to evidence presented at trial, Dr. Agresti also had Good Decisions Sober Living patients sent to his own medical practice to fraudulently bill for services. 

Dr. Agresti was convicted of 11 counts of healthcare fraud and one count each of conspiracy to commit healthcare fraud and wire fraud. He is scheduled to be sentenced April 21.