Not-so-fine Print

Posted Jan. 27, 2010, at 5:17 p.m.

If anyone still needed an example of the power health insurance companies have to control their own economic destiny, and how that power can devastate health care providers and patients, there’s a new one here in Maine.

The insurance company in this case, Anthem Blue Cross and Blue Shield of Maine, changed its policy on claim submissions with little notice, leaving the VA Togus Medical Center in Augusta on the hook for $500,000 in unpaid insurance claims. The company finally relented, but it took pressure from 1st District Rep. Chellie Pingree. The case illustrates the need for the federal government to step up its regulation of health insurance companies.

Anthem denied $500,000 in claims for patients who are covered under a private insurance plan for federal employees — because they were not filed in time, Togus officials reported. For years, Anthem gave health care providers like Togus until Dec. 31 of the year after the service to file the claim. The problem was, Anthem then changed its policy so claims had to be filed within 120 days of service.

“The only notification of this change in policy,” Rep. Pingree wrote in a Jan. 13 letter to Anthem President Daniel Corcoran, “was a small item on the second page of an Anthem newsletter — a newsletter that Togus officials have no record of ever receiving.” Such “fine print” rulings are not un-common; throughout the recent push for health care reform, dozens of similar horror stories of unilateral insurance company decisions have emerged.

Rep. Pingree argued that even if Togus officials knew of the change, complying would be next to impossible with existing staff. The hospital, she wrote, “is already struggling with budget shortfalls.”

The policy change “seems like an arbitrary decision intended to give an insurance company an excuse to deny legitimate claims for service,” Rep. Pingree wrote.

Anthem relented and is working at reimbursing the claims, Mr. Corcoran wrote in a Jan. 20 letter to Rep. Pingree.

The resolution might not have been so quick and friendly had the insurance company denied the claims of a small private hospital. And this highlights the need for more government oversight. It should not take a letter from a member of Congress to get fair play from an insurance company that holds so many cards.

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