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Anthem fined $5 million by Georgia insurance officials over claims processing errors

The fine was a result of claims processing errors beginning in 2015.

ATLANTA — Anthem Blue Cross Blue Shield was fined $5 million by Georgia insurance officials over claims processing errors that evidently emerged following the implementation of a new database system in 2015.

According to an agreement between Anthem and the state, those errors most significantly included in-network claims processing as out-of-network, resulting in the company being out of compliance with claims timeliness requirements for "several quarters" between 2018-21. 

The Georgia Insurance Commissioner's Office announced the fine on Tuesday, saying that a months-long examination into company practices found "violations of state laws and agency rules and regulations."

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A consent order between Anthem and the state, which did not require Anthem to admit or deny it had violated any laws, asserted the company debuted a new "internally developed provider database system" in May 2015 that was to "consolidate provider data and to serve as a centralized data repository for all Anthem provider demographic data."

After that, complaints to the state from healthcare providers "noticeably increased" as the providers encountered processing errors with the new system.

According to the consent order, those most commonly included:

  • "claims from in-network providers processing as out-of-network"
  • "claims rejecting for unknown reasons"

The consent order said a "significant number of claims were impacted" by these issues.

Anthem then began to develop a replacement system, which was not released until April 2021. During that time the company "continued to experience processing errors" with the old system, the consent order says, and failed to adopt procedures for promptly investigating and settling claims as required by law.

Anthem provided the following statement:

Anthem Blue Cross and Blue Shield ­strives to process and pay claims as quickly and efficiently as possible in accordance with provider agreements and applicable state laws and regulations. The department’s exam focused on a ­provider database system that was implemented in Georgia nearly seven years ago and is no longer in use. As the department is aware, we worked diligently to address these challenges. We have since migrated to a new platform with the goal of improving accuracy and transparency. We are dedicated to those we serve and partner with, and we believe the recent enhancements we have made will create an improved overall care provider experience.

In addition to the fine, the consent order calls for a "corrective action plan" that will require monthly reporting "demonstrating compliance" with the plan until March 31, 2023. The Insurance Commissioner's Office may end the reporting requirement sooner at its discretion.

Anthem will also be subject to "periodic examinations" by the state, and any further provider complaints must be responded to within 15 days. The company will have to give 120 days' notice to the state prior to implementing any more new systems.

Lastly, Anthem will not be allowed to pay an ordinary dividend to shareholders of more than $100 million, or any other dividends, without insurance commissioner approval until the expiration of the supervision period at the end of March 2023. 

   

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