Anthem Blue Cross dba Blue Cross of California has a history of failing to resolve the grievances of their consumers in a timely fashion. In fact, the problem is so severe that in late 2017, California’s managed-care regulator fined the insurance giant $5 million for its failures in this area.
From 2013 to 2016, California government found 245 grievance-system violations at Anthem. Furthermore, in 2016, insurance company denials were overturned in almost 70 percent of medical review cases. However, appealing these denials and getting them overturned can be difficult for even the most insurance-savvy consumer.
If you were wrongly denied an Anthem insurance denial appeal, you do not have to simply accept the denial. A Los Angeles Anthem health insurance denial appeals lawyer can help you take action to get the coverage you need.
Common Reasons for Health Insurance Denials
Health insurance companies such as Anthem are in the business of providing health insurance and of making money. In some instances, health insurance carriers may do everything they can to deny claims to increase their profits. This can be extremely infuriating for the millions of policyholders who faithfully pay their premiums each time they are due.
Common reasons for health insurance claim denials include:
- The service or medical device sought is not medically necessary
- The service sought is investigational or experimental
- The filing deadline expired
- The insured received two services in one day
- The policyholder changed their insurance plan
- The out-of-network benefits are different from in-network benefits
- The insured did not reach their deductible
- The individual made a late payment to COBRA
- The person lacked a physician referral
- The policyholder had a certain procedure that was not covered
For more information or help with filing a claim, get in contact with a Los Angeles Anthem health insurance denial appeals lawyer today.
Applicable Laws in Anthem Appeals
Anthem is a commercial enterprise that must answer to a higher chain of command. Most voluntarily established health insurance plans in private industry, i.e. group employer plans, fall under the requirements set by the Employee Retirement Income Security Act of 1974 (ERISA). Under this federal law, health insurance companies such as Anthem must provide their plan participants with plan information including the funding of the plan and who has fiduciary responsibilities.
Insurance companies are also mandated by this law to establish a grievance and appeals process for their participants. The law also provides plan participants the right to sue for benefits and breaches of fiduciary duty.
Health plans and health insurers that are not governed by ERISA in California are subject to various laws in the California Insurance Code and the California Health and Safety Code, such as the Knox-Keene act.
Those who work with a Los Angeles Anthem health insurance denial appeals lawyer may be able to increase their chances of acceptance for their claim or appeal.
What is the Typical Process for Filing a Complaint or Grievance with Anthem?
You may wonder how you file Anthem complaints and grievances or how to appeal an Anthem denial. You can request a coverage decision, appeal, or make a complaint (grievance) by looking at the section of your Evidence of Coverage document titled “What to Do If You Have a Problem or Complaint.” This document helps you know what to do if you are not getting the benefits you believe are covered under your insurance plan. It also details how you can ask Anthem to make an exception in certain cases or you can request that hospital care or certain types of medical services be covered when you think your coverage ended too soon.
If you have a complaint about the company or how you were treated, you can file a grievance. This usually involves calling Customer Service and letting them know what your grievance consists of. If you are not satisfied with the answer you receive from the Customer Service representative, you can put your complaint in writing and send it to Anthem. If your Anthem complaints or grievances are not handled professionally or not resolved, talk to your attorney about your next steps.
How Can You Appeal an Anthem Denial?
Perhaps you have received a denial of treatment from Anthem and need to know how to appeal an Anthem denial, or what the Anthem appeal process consists of. Anthem may claim that the treatment or prescription drug that has been denied was denied because it was “not medically necessary,” or is “experimental” or “investigational.” This usually means that the drug or treatment is expensive, and Anthem does not want to pay. If your issue relates to a service, treatment, or prescription drug that has been denied by Anthem, you can appeal the decision. An appeal is a formal way of asking Anthem to review its initial decision and pay for the denied treatment, service, or drug.
Your attorney may include a letter from your physician that details why the treatment, test, or drug is necessary for your health. If the internal appeal is unsuccessful, your attorney can help you file an external appeal which asks a neutral third party to look at the denial and reverse the decision. If you have Anthem as your Medicare insurer and you are unhappy with the company’s actions or denial of services, you can submit a Medicare complaint form to the Appeals and Grievances Department. You can also contact the Medicare Beneficiary Ombudsman—a person at the Centers for Medicare & Medicaid Services who can assist you.
How Can an Attorney Help You with the Anthem Complaint and Anthem Grievance Process?
When you are sick, dealing with the Anthem appeal process, or submitting Anthem complaints and grievances can feel overwhelming. This is a time when you need an experienced, highly skilled attorney who can help you through this difficult time with the best outcome possible. If Anthem has not lived up to the promises it made to you, or it has failed to fulfill its end of the bargain—even though you have faithfully paid your premiums—don’t give up. An experienced Anthem insurance denial attorney from The Law Offices of Scott Glovsky can help you fight for the benefits you need and deserve.
When you are facing an insurance denial from Anthem, it can be daunting to go up against a huge insurance company. These large insurers usually find ways to justify their denial decisions by claiming the treatment was not medically necessary, alleging you deliberately used an out-of-network provider, or saying you misinterpreted information in your insurance plan. Your attorney can help ensure that an internal appeal has full documentation to give it the best chance possible of a denial reversal. Attorney Scott Glovsky has been helping his clients with insurance denials for more than two decades. Scott knows which strategies and techniques work best when filing an internal appeal.
If your internal appeal is unsuccessful, Scott can help you file an external appeal. An external appeal involves a neutral third party. Whatever decision this third party makes is binding on the insurance company. Scott has dealt with Anthem and other insurance companies many, many times. Taking into consideration all the unique facts and circumstances of your denial or grievance, Scott and his knowledgeable legal team will craft the best legal strategy available. Scott Glovsky has experience working with large corporate law firms defending insurance companies, so he has a deep understanding of how these insurers think and operate. Scott is well-respected in the industry and has a solid reputation for integrity, experience, and top-tier client care and attention.
Let a Los Angeles Anthem Health Insurance Denial Appeals Attorney Help
If you need help dealing with a health insurance issue, consult with an attorney. A well-versed attorney is familiar with the games insurance companies such as Anthem can play and have experience getting policyholders the coverage they need and deserve.
A compassionate lawyer’s goal is to get Anthem to take steps towards reviewing your appeal and possibly getting them to accept your claim. Contact a Los Angeles Anthem health insurance denial appeals lawyer today to learn more about how they can help you.