Attorney Scott Glovsky Helps Those Denied Insurance Coverage
Scott Glovsky is the tough, aggressive insurance denial attorney you need when your claim with Anthem Blue Cross of California has been denied. Scott is personally involved in each and every case taken on by the Law Offices of Scott Glovsky. When you hire the team, you hire Scott Glovsky. Scott works directly with every client—and truly cares about every client. Scott takes on fewer cases so he can personally devote the tremendous amount of time and effort necessary to represent his clients. Scott Glovsky can beat up your insurance company—just ask Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser, Aetna, and United Healthcare.
About Anthem Blue Cross of California
Anthem is the second largest provider of health insurance in the United States, and the largest for-profit managed healthcare company in the Blue Cross Blue Shield Association. In June 2022, Anthem’s parent company rebranded itself from Anthem, Inc. to Elevance Health, Inc. It also launched the Carelon brand that includes its pharmacy benefit manager and care delivery services. As of February 2024, Anthem serves 118 million customers. Elevance Health has Blue plans (Blue Cross Blue Shield) in fourteen states as well as Medicare and Medicaid plans through its Wellpoint subsidiary. (Note that in California, Blue Shield of California and Anthem Blue Cross are separate health insurance companies.)
In 2012, WellPoint acquired Amerigroup for $4.9 billion under the theory that the Affordable Care Act would result in significant Medicaid expansion. Before 2014, Anthem was called WellPoint, formed by the 2004 merger of California’s WellPoint and Indianapolis’ Anthem. Anthem Blue Cross in California has about 800,000 customers, making it one of the largest health insurers. Anthem attempted to acquire Cigna in 2015 for more than $54 billion, but in 2017 that merger was blocked by a U.S. District Court.
In October 2017, Anthem decided not to renew its relationship with Express Scripts that offered pharmacy benefit management, claiming Express Scripts had overcharged Anthem by $3 billion. Instead, Anthem announced it would enter into a 5-year contract with CVS Health, then only a few months later announced plans to acquire Express Scripts for $58 billion. Unfortunately, in 2011, the California state patient advocacy office gave Anthem a rating of 2 out of four stars in the category of “Meeting National Standards of Care.” Anthem had another scandal in 2007 when it was investigated for revoking health care insurance policies. And in October 2022, a federal judge decided the DOJ’s 2020 lawsuit against Anthem for allegedly using incorrect diagnosis codes in its Medicare Advantage plans to fraudulently collect potentially over $100 million from Medicare will move forward.
In February 2023, Elevance acquired the Specialty Pharmacy BioPlus. Specialty pharmacies focus on patients with complicated conditions such as multiple sclerosis and cancer. Elevance plans to leverage medical and pharmacy insights to connect patients to other whole health services such as behavioral health and in-home care. BioPlus will operate as part of the company’s pharmacy benefit manager, CarelonRx.
The California Department of Managed Health Care randomly selected 90 instances in which health care insurance policies were canceled by Anthem after the insured individuals were diagnosed with a life-threatening or particularly costly illness. The DMHC determined all the cancellations were done illegally. To resolve the allegations that Anthem improperly canceled health insurance policies, they paid $10 million to the California DMHC and reinstated plans for 1,779 policyholders. As a part of the settlement, policyholders’ medical debts incurred by the cancellations were also to be paid. By 2011, Anthem canceled policies of members who paid by credit card, often with no warning.
In 2022, California’s Department of Managed Healthcare (DMHC) fined Anthem $1.1 million. Anthem’s violations included erroneously applying practitioner office visit costs to policyholder deductibles and failing to mail EOBs (Explanation of Benefits) to policyholders in 2019. Anthem also reimbursed impacted members $9.2 million and agreed to take many corrective actions. EOBs are important since they include information about how to appeal a decision. These documents also communicate out-of-pocket payments and amounts applied to policyholder deductibles.
In 2022, the DMHC overturned 64.6% of Anthem’s medically necessary Independent Medical Reviews (IMRs) and Anthem reversed its prior denial in 10% of the appeals. So members who submitted external appeals got the healthcare they needed in nearly 75% of the cases. The numbers for 2021 are similar. The DMHC overturned 65% of IMRs and Anthem reversed its previous denial in 9.6% of cases.
Understanding Health Insurance Denials and Appeals
When your insurance company sends you notification that they will not cover the cost of your medication or treatment, it can be frustrating, not to mention stressful when you are unable to pay for necessary treatment or medication. The only good news associated with a health insurance denial is that you do have the right to appeal the decision. Learn about how to fight a health insurance denial in our eBook.
Unfortunately, appealing a denial of coverage can be both time-consuming and overwhelming. The first step is to understand why you received a denial in the first place. In most cases, your health insurer will send you a document known as an Explanation of Benefits. Once you know why your treatment or service was denied, you may decide to file an appeal, which asks your insurance company to reconsider its initial decision.
There is good reason to appeal a denial; you have nothing to lose and many denial appeals are ultimately successful. Despite the fact that you have a fairly good chance of winning your appeal, the process can be daunting. Typically, you will appeal internally through Anthem Blue Cross of California as a first step. You will contact your insurer, requesting they reconsider the denial. Your goal in this first appeal is to show your treatment or service meets the insurance guidelines, and that it was incorrectly rejected. The appeals process can cause you much less anxiety when you have a strong legal advocate by your side from start to finish. Scott Glovsky has been helping people just like you for two decades, get the healthcare they were promised by their insured.
Why Anthem Blue Cross of California Might Have Denied Your Claim
While there are many reasons your claim might have been denied, some of the most common reasons include:
- The treatment or service denied by your insurance company may not be deemed medically necessary.
- Your treatment plan or service is seen as experimental.
- There are clerical errors, such as misspellings or typos in your original paperwork or there are data entry errors on the claim or insurance policy number.
- The physician you saw was not in your plan or out-of-network.
- You failed to obtain pre-authorization for the procedure or service or did not have a referral from your doctor to see a specialist.
When you have been denied by Anthem Blue Cross of California, it is important that you adhere to the time limits set forth under your plan for filing an appeal. Missing your window of opportunity can be grounds for immediately denying your appeal. Under Anthem Blue Cross of California, you must file an appeal within 60 calendar days of the date on your denial letter. If you have a very good reason why you were unable to file your appeal within the 60 days, you can submit a written request that explains why you could not file within the allowable 60 days.
Either you or your physician can ask for an expedited appeal if waiting on a standard appeal would cause serious harm to your health. Expedited appeals are not available if your request is regarding payment for care you have already received. An Anthem Blue Cross of California health insurer denial lawyer like Scott Glovsky can help you through the entire appeal—first the internal appeal, then if your appeal is denied, through the external review.
FAQs Regarding Anthem Blue Cross of California Coverage Denials
If you have been denied healthcare coverage by Anthem Blue Cross of California, you may have many questions, including:
What is the difference between denied claims and rejected claims?
A health insurance claim denial is when an insurance company does not approve payment for a specific claim. A rejected claim occurs because of improper processing, due to incorrect information on the health insurance claim form. Rejected claims do not require an appeal, you must simply fix the error(s) and resubmit the claim with the correct information.
What types of denials can go to an external review?
Any denial that involves medical judgment (you or your doctor disagree with your insurer as far as medical necessity, appropriateness, level of care, effectiveness of covered benefits, or health care setting) can be taken to an external review. If you were denied because your treatment is considered experimental, then you can take the appeal to an external review. If your denial of coverage was due to discontinuation of your healthcare, or a retroactive cancellation of your health insurance, you can ask for an external review. According to the Department of Managed Healthcare, of all medical necessity external appeals (AKA Independent Medical Reviews) filed against Anthem in 2022, 74.6% of these policyholders ultimately received the medical care they appealed in the IMR.
How long will my external review take?
While a “standard” external review will usually be decided as quickly as possible, it can be up to sixty days after receipt of your review request.
What rights do I have in an external review?
There are minimum consumer protection standards outlined in the Affordable Care Act or the State of California could have external review processes that meet or exceed these standards. If so, health insurers like Anthem Blue Cross of California will follow the state’s external review processes, and you are entitled to all protections outlined in that process.
News Related to Anthem Blue Cross of California
In late 2019, the State Department of Managed Health Care hit Anthem Blue Cross with almost $10 million in fines for the period of January 2014, through November 2019. That amount was only about 44 percent of the $21.7 million in penalties assessed by the department, even though Anthem covered only 10-13 percent of Californians with department-regulated plans.
By comparison, Kaiser Permanente covered almost a third of Californians in department-regulated plans during the same timeframe but received 11 percent of the penalties. Anthem Blue Cross of California had more actions as a result of its historical failures to properly identify and handle grievances and appeals from those it insures. Anthem’s fines related to the 553 enforcement actions taken against the company for violations including inappropriately denying claims, or not covering the cost of out-of-network care that should have been covered.
- Department of Managed Healthcare Issues Report on Anthem Blue Cross Narrow Networks: Validates Our Class Action (Cowart v. Anthem Blue Cross)
- Class Action Suit Filed For Anthem Data Breach Victims
- Blue Cross of California dba Anthem Blue Cross’s unlawful misrepresentations to EPO members
- Anthem Fined $5 Million by the State of California for Ignoring Consumer Complaints
- Large Companies Face Criticism of Relationship with Neutrals
- LA Times Covers Insurance Company’s Denial Of Treating Physician’s Recommended Treatment Option
- Anthem Blue Cross Policy Change Frustrates Doctors – In 2018, Anthem issued guidelines recently that indicate that it will only pay for magnetic resonance imaging (MRI) and other forms of electronic imaging if those services are provided at a free-standing imaging center.
- Anthem’s New Anesthesia Policy Comes Under Scrutiny – In 2018, Anthem announced that it would no longer pay for intravenous anesthesia in most cataract operations.
- Anthem Blue Cross Policy Change May Result in Inappropriate Treatment Decisions – The third-largest insurance provider in California issued a policy that limits the ability of a doctor to determine the best method of anesthesia for an operation.
- New Case: Balkis v. Anthem Blue Cross – The Law Offices of Scott Glovsky filed a complaint against Anthem Blue Cross, in Los Angeles Superior Court Case No. BC614807, for the wrongful termination of “Mike” Ahmed Balkis’ health insurance policy and the wrongful denial of medication that he requires to treat a severe form of Crohn’s disease, an inflammatory bowel disease.
- Federal Government Paying Out Nearly $8 Billion to Health Insurers – 2015, The federal government is paying out nearly $8 billion to health insurers under a reinsurance program.
- Blue Cross of California dba Anthem Blue Cross Denied Coverage To Replace A Medically Necessary Cardiac Monitor For Los Angeles Man, Law Offices of Scott Glovsky Lawsuit Alleges
- KTLA – Patient Sues Blue Cross For Denying Liver Transplant – The lawsuit was filed by 61-year-old Ephram Nehme, a Lebanese immigrant, who claims he was automatically denied coverage for a liver transplant that his doctor said was medically necessary to save his life.
- Fox LA – Blue Cross sued for Cost of Transplant – Blue Cross of California should pay the $205,000 cost of a liver transplant for a man who went to Indiana for surgery because the wait in California would have been fatal, a lawyer said in the opening statements on Monday in the suit against the insurer.
- LA Times – Trial begins over lawsuit targeting Anthem Blue Cross – Ephram Nehme’s request to have liver transplant done in Indiana, where wait times are shorter, was denied by his insurer. The firm’s attorney says he wasn’t sick enough to go out of network.
- Nationally-Recognized Insurance Lawyer Helping California Anthem Blue Cross EPO Members – Anthem sent misleading membership cards to members of Anthem’s EPO. The membership cards indicated that the members’ subscribed to a preferred provider organization (“PPO”) plan instead of an EPO plan.
- Anthem Blue Cross Life and Health Insurance Company Cancelled Coverage Policies for Members Across California Without Adequate Notice – Scott Glovsky of The Law Offices of Scott Glovsky filed a class action lawsuit in Los Angeles Superior Court on behalf of Sandra Markus and all other similarly situated Anthem Blue Cross Life and Health Insurance Company members in California against the Anthem entity alleging claims for breach of contract and declaratory relief.
- Former Police Captain Continues to Fight Anthem Blue Cross Denial for Medically Necessary Back Surgery – Retired Los Angeles Police Department Captain, Joel Justice, filed a lawsuit against Anthem Blue Cross. Joel Justice is fighting the Anthem Blue Cross denial for coverage for a spinal decompression and fusion surgery that Joel’s neurosurgeon, Dr. Igor Fineman, deemed medically necessary. The case is Justice v. Blue Cross of California dba Anthem Blue Cross, Los Angeles Superior Court Case No. BC709255.
How Attorney Scott Glovsky Can Help if You’ve Had a Coverage Denial from Anthem Blue Cross
It is likely you expect your health insurance to cover necessary treatments and services—after all, you pay your premiums each and every month. Insurance companies like Anthem Blue Cross of California may engage in actions to deny you coverage should you fall ill, require a medical procedure or test, or need a specific prescription drug. Scott Glovsky is the Anthem Blue Cross of California health insurance denial lawyer you need should you be forced to fight your insurance company to pay for necessary treatments, tests, or services.
Scott recovered roughly $25 million from Anthem Blue Cross of California, based on the company misleading Californians regarding doctors within their network. Scott will never back down from a fight and will file an appeal on your behalf through the internal processes of Anthem Blue Cross, present your case before the state review board, or take your case to court to force Anthem to live up to their promises. You may wonder why you should choose the Law Offices of Scott Glovsky. Scott is personally involved in each and every case, so when you hire the firm, you hire him. As your trial lawyer, Scott will ensure he knows your case inside and out. Even more, Scott will learn your story—after all, he cannot fully tell your story unless and until he knows you and knows your story.
If Anthem Blue Cross of California denied your health insurance claim or ER visit, contact Scott Glovsky today to find out how we can help you during this difficult time. We want to make sure you get the treatment you need, while also making sure Anthem provides the coverage you were promised. You need and deserve the treatment or service your insurance company pledged to provide, and you also need a legal advocate in your corner who can help make that happen.