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Deceptive Trade Practices and Fraud: Anthem Blue Cross and Blue Shield, Los Angeles, CA
Earlier in the year I saw 2 doctors that pre-certified my insurnace overage. 2 months ago I recieved EOB's stating they would not pay based on the information they had re: other coverage. 1 month ago I received a survey re other coverage that I used to state there is none and mailed back at my expense. This week I received a EOB stating that they are denying payment for failure to provide requested information on other coverage, and that I would have to appeal for further consideration under ERISA. They have always and still collect my premiums.
Anthem Blue Cross and Blue Shield
PO Box 54159
Los Angeles, CA [protected]
The complaint has been investigated and resolved to the customer’s satisfaction.
Anthem policies allow a legal, but unethical Bait & Switch Gotcha to bilk patients.
Going to an In-Network hospital or provider is not enough. I thought I was “safe’ going to an In-Network hospital. Simplifying, I went to an In-Network hospital ER and was given an ultrasound by a contractor that is Out-of-Network, who was assigned by the hospital. Until I received the Anthem statements, it was unknown to me that the In-Network hospital would send an Out-of-Network contractor into my room.
Problems:
a) The Out-of-Network contractor can charge me whatever they want and do not have to accept the Anthem amount allowed by my benefit.
b) Anthem may pay only 50% (of their amount allowed by the benefit) for Out-of-Network services. The patient may be forced to pay any delta costs.
c) This Out-of-Network charge is applied to a different deductible than the In-Network deductible. It is unlikely the patient will fulfill their Out-of-Network deductible in a year, so this is wasted.
d) Information about this issue will occur AFTER the services have been administered and AFTER the patient can make an informed decision about his/her options.
e) This applies regardless of whether the patient is coherent.
f) This can be a SIGNIFICANT cost to the patient.
This is effectively a Bait & Switch operation by the hospital or provider (doctor) and totally accepted by Anthem policies. Even though it is unethical, it is legal because of the small, fine-print forms we patients all sign these days.
What can you do?
If your In-Network physician refers you to ANY other service provider, ASK if they are In-Network BEFORE services occur.
If you In-Network hospital refers ANY doctor or service provider, ASK if they are In-Network BEFORE services occur. (You can choose to allow an Out-of-Network contractor if no other option is available, but at least you know beforehand.)
“Protect” incoherent patients as much as possible by having another person there to ask if everyone providing services are IN-Network.
Complain to Anthem and ask them to change their policy or at least put pressure on the hospital to hire contractors that will accept Anthem allowed expenses. The real solution is a policy change by BlueCross. The hospital should also be forced to notify the patient that the contractor is Out-of-Network.
Does anyone have a contact number. I wrote them in Dec 1, 2013 requesting an external review. I have not heard from a single person. I have followed all procedures and am frustrated that I can not each someone to talk to since it seems that my mail went to the trash can. This is why I don't have insurance now. I hate these crooks. Thanks Bettina Burnette
I live in CT. In need of surgery; cervical spinal fusions. Three times in the last 5 months Anthem has approved me for surgery over the phone without sending the proof of approval forms to me; I don't know what they are called. I've requested the forms many times, no response. My doctors office say that all three times Anthem has denied my request for surgery and is not providing them with appropriate paperwork stating that fact. How can I appeal a denial which I haven't received? How can I pursue this without a paper trail. I have myself made notes on dates when I have contacted Anthem, that's all I have. How to proceed from here? How do I chase a ghost? I contacted the CT State Ins. Commission. Please give me advice. Thank you.
I absolutely agree this such of situation is happening for I am a provider in VA and have dealt with these situations where ee works for ex. Lord and Taylor (and therefore has Anthem of CA) but gets her services in VA and Anthem does not pay the provider or patient unless you spend hours and hours disputing the case with them.
Did a little research and found Anthem Blue Cross, Blue Cross and Blue Shield of California, and Wellpoint have been sued for failing to reimburse patients for out-of-network costs. They have a brief item about the litigation, plus you can download a report by the New York AG, or sign up to participate in the action. http://www.classactionfaq.com/consumer-fraud/bluecross/