ComplaintsforAnthem Blue Cross and Blue Shield

• Initial Complaint

  08/26/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  On 02/02/2024, I had surgery performed by Apex Dermatology in Westlake Ohio by *** ******. The total surgical cost was $2023.72 which Anthem denied stating the service performed is not covered under your plan. However, the service is covered. I contacted Anthem and spoke to a representative who was confused by why the claim was not paid and sent the claim back to be reviewed. Additionally, Apex filed an appeal on the claim and to this date no one has ever responded to the appeal complaints. Then on 06/25/2024, I had an office follow-up visit with Plastic Surgery ****** ***** at the Cleveland Clinic regarding complications from the surgery performed on 02/15/2024. The total office visit was $423.00 which Anthem denied stating the service performed is not covered under your plan. However, the service is covered, and additionally, I have reached my 100 percent deductible. I again contacted Anthem and spoke to a presentative who sent the claim back to be reviewed and to this date, no one has ever responded to the appeal complaints. Then on 08/12/2024, I had an office follow-up visit with Plastic Surgery **** ******** at the Cleveland Clinic again regarding complications from the surgery performed on 02/15/2024. The claim amount was for $624.00 which was denied on 08/21/2024 stating the service performed is not covered under your plan. I again contacted Anthem and spoke to a presentative who sent the claim back to be reviewed (reference #: **********) however, with the two previous issues still unresolved I feel questionable the third one will have the same outcome.

  Business response

  09/06/2024

  Good afternoon,

  Please see attached response. Thank you.

   

  Customer response

  09/10/2024

  
  Complaint: ********
  
  I am rejecting this response because:

  Attached along with this complaint is a signed Anthem HIPAA form authorizing Anthem to communicate with the BBB regarding the complaint. The form was signed and dated on 08/26/2024 so I’m somewhat confused to the response from Anthem.

  
  Attempting to file verbal appeals for the past 7 months and never receiving a response was why I felt I had to turn to the BBB for help regarding this process. I have called Anthem dozens of times regarding these denied claims and have never heard back on any of them until after I filed the BBB complaint on 08/27.

  
  Shortly after filing the complaint, on 09/05 I received 2 center messages from Anthem that two claims had been reversed because of processing errors (************* & *************) and was finally told by phone what the billing error was on claim ************* and Apex was contacted and they are making the corrections (7 months later) and resubmitting the claim.  I was also advised by phone that claims ************* and ************* were sent back to be reviewed and there appeared to be confusion why the claims were denied in the first place.

  
  Based on Anthem’s response and not attempting to resolve the issues listed in the complain I respectfully request that the BBB leave this complaint open until Anthem agrees to attempt to resolve the issues listed in this complaint.
  
  Sincerely,
  
  ***** *******

  Business response

  09/17/2024

  Good afternoon,

   

  Please see attached response. 

  Dear ******** **

  The Better Business Bureau (BBB) has notified Anthem Blue Cross Life and Health Insurance Companies (Anthem) that you have contacted them recently requesting their assistance regarding the above-referenced file number. Your case has been assigned to me for special handling.

  Your request states the following:

  “I am rejecting this response because:

  Attached along with this complaint is a signed Anthem HIPAA form authorizing Anthem to communicate with the BBB regarding the complaint. The form was signed and dated on 08/26/2024 so I'm somewhat confused to the response from Anthem.

  Attempting to file verbal appeals for the past 7 months and never receiving a response was why I felt I had to turn to the BBB for help regarding this process. I have called Anthem dozens of times regarding these denied claims and have never heard back on any of them until after I filed the BBB complaint on 08/27.

  Shortly after filing the complaint, on 09/05 I received 2 center messages from Anthem that two claims had been reversed because of processing errors (************* & *************) and was finally told by phone what the billing error was on claim ************* and Apex was contacted and they are making the corrections (7 months later) and resubmitting the claim. I was also advised by phone that claims ************* and ************* were sent back to be reviewed and there appeared to be confusion why the claims were denied in the first place.

  Based on Anthem's response and not attempting to resolve the issues listed in the complain I respectfully request that the BBB leave this complaint open until Anthem agrees to attempt to resolve the issues listed in this complaint.

  After reviewing the complaint, our records indicate that the member is under an Anthem Blue Cross Life and Health Insurance Companies (Anthem) self-funded plan. The Plan reiterates that the documents provided by the BBB/member, did not provide a valid signed and dated consent form authorizing Anthem to disclose PHI, case docs, etc. to the BBB. Therefore, the Plan (Anthem) respectfully requests that the BBB remove this complaint from your file. The member is advised to submit their appeal to the following, as per their appeal rights under the plan that they are insured.

  The member may contact our customer service department at the telephone number on their Anthem identification card for assistance in obtaining a copy of their Evidence of Coverage for information regarding their appeal rights.

  Anthem Blue Cross Life and Health Insurance Company ATTN:

  ******* **** *** ***** ******** ****** ** **********

  I hope you find this information helpful. If you have any questions or need more information, please call me directly at **************.

  Best regards,

  **** *********

  Grievances and Appeals Risk Analyst

  Grievances and Appeals

  Risk Management

  Customer response

  09/18/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ******** and find that this resolution is unresolvable using this method to communicate with this company. I like to thank you for your help in attempting to resolve this issue. 
  
  Sincerely,
  
  ***** *******

• Initial Complaint

  12/13/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  On October 3, 2023, my wife reached out to Anthem to see if a provider was in our network for a procedure that our daughter would be needing. The agent that my wife spoke with told us that the procedure was covered under our policy and that the provider was in our network. After the procedure was completed on October 10, 2023, we received a bill saying that insurance would not cover the procedure because it was out of network. I have provided the chat that my wife had with the insurance agent assuring us that the procedure would be covered under our current policy. We wish to recover the $700.00 that we had to pay out of pocket because we were lied to by this deceiving company.

  Business response

  12/21/2023

  Dear Marketplace Services Coordinator:

  
  We are responding to your inquiry from **** *****, regarding his daughter, ***** *****. *** ***** will need to contact Member Services, at the phone number on the back of his
  identification card, regarding this issue.

  
  Sincerely,

  
  ******** **
  Risk Analyst
  Grievances and Appeals

• Initial Complaint

  06/22/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  FORMAL COMPLAINT AGAINST ANTHEM, INC. AND ANTHEM'S SUBCONTRACTOR LIBERTY DENTAL Issues: Ethics and Business Practices of Anthem, Inc, and Liberty Dental, Applicable to Diabetic Shoes Claim of 2023 and Dental Claims of 2021 and 2022 Diabetic Shoes Claim: On 6-2-23, I received a cedl from ****** Clinic, advising me that I had a co-payment of $68.+ for my ordered diabetic shoes. Amy, at Hanger, advised me that an Anthem representative told her “There's a $4600.00 and 80/20 rule”. Now that sounds really impressive! That's true! There is a $4600.00 rule. Actually, it's a $4660.00 rule that applies to drugs and not to diabetic shoes. There's also a 80/20 rule. It applies to DME (Durable Medical Equipment) and not to diabetic shoes. On page 50 of the Anthem 2023 plan documents medical benefits, it specifically states, “$0.00 copay for therapeutic shoes, including fitting the shoes or inserts”. Whereupon, I immediately called Anthem, talking to *****any, who claimed that ****** should advise Anthem of a reference number. On 6-5-23, I called Anthem, talking to ***** F of Texas, reviewing the copay issue. ***** advised me that Anthem needed an authorization number from Hanger, The reference number matter seemed to disappear. I later learned that the reference number and the authorization number are not the same. On 6-7-23, I called Hanger, talking to ******, who advised me that no authorization is necessary. I gave ****** ******* telephone number. On 6-8-23, ****** said that she advised Anthem that there is no copay for these diabetic shoes and that ****** has documentation that an authorization number is not required. On 6-9-23, Anthem's ******** * of Texas told me that ****** needed to provide an authorization number. However, within minutes, ***** advised me that an authorization number was not necessary, and that there is no copay for these shoes. On 6-12-23, at 3:41 P.M., ****** advised me that ******** from Anthem had called on 6-9-23 and ****** was told that an authorization number was not necessary, and that there is no copay for these shoes. Confusing? Conflicting? Deceptive? This issue has taken 3 hours and 9 minutes of my time, and having tied up telephone for 3 hours and 9 minutes. Dental Claim: On 6-5-23, much to my surprise, I received a bill of $70.00 from my dentist's office, Drs. **** ***** & ****** ************, applicable to a claim on 12-21-22, because after a series of previous telephone calls, on 3-8-23,1 talked to Liberty Dental's ******** in California, who promised to call Dr. *****'s office, and she advised me that this claim will be paid, also that my dental coverage record will be corrected to avoid repetition of this type of problem. On 6-5-23, I called *****, at Anthem, and reviewed the 12-21-22 dental claim with her. She promised to call me on 6-7-23 A.M., after she had reviewed this claim. On 6-7-23, ***** of Anthem, ******* of Liberty Dental,and I had a conference call, wherein ******* told us that the dentist's office needed to resubmit the 12-21-22 claim to be reviewed and reprocessed, which will take 7 to 10 days by Liberty Dental. ***** claimed that she needed more time to investigate this claim, advising that ******** had lied to me on 3-8-23. ***** promised to call me within 48 hours. On 6-7-23, I called Cailee, at the dentist's office. While we were on the telephone together, she resubmitted the dental claim of 12-21-22 on 6-7-23 at 3:29 P.M.. On 6-9-23, ***** did not call me as promised. I had to track her down with the help of ******** L of Texas. *****, *******, and I had another conference telephone call, in which ******* repeated the review, reprocess, and 7 to 10 days prescribed by Liberty Dental's guidelines. ******* admitted that Liberty did have th 12-21-22 dental claim. This dental claim of 12-21-22 is virtually the same, except for the dates, as the dental claim of 9-1-21, in which I filed a formal complaint (like a legal brief with exhibits), costing me $17.12 in postage expense. The postage expense was “cannot be granted as it is not part of the plan's paid covered benefit or service” by Anthem. The dental claim of 2021 was paid, taking over 3 hours and 21 minutes of my time, and having tied up my telephone for over 3 hours and 21 minutes. There seems to be a pattern of attempted theft by deception. PLEASE SHARE YOUR THOUGHTS WITH ME. The dental clam issue of 12-21-22, at this point in time, has taken 6 hours and 3 minutes of my time, and having tied up my telephone for 6 hours and 3 minutes. My experience leads me to conclude that their behaviors are based on a providers playbook; That is: refer, refer: put on hold numerous times, even disconnect, while on hold; repeated unproductive multiple referrals; when that didn't work, then double talk: when that didn't work, promise to call back and not call back; when that didn't work, need more time to investigate (the stall tactic); when that didn't work, then out-and-out lies.

  Business response

  07/10/2023

  July 10, 2023
  
  
   Better Business Bureau of Dayton/Miami Valley, Inc.
   Attention: ******** *.
   ** **** ****** ******* ***** ***  ******* ** *****
   VIA Portal Upload
  
  Member Name: **** *****
  
  Re: Medical and Dental Claims
  BBB File No.: ********
  
  
  Dear BBB:
  
  This is in response to your correspondence dated July 6, 2023, regarding the above referenced member.
  
  Due to federal laws pertaining to the Health Insurance Portability and Accountability Act (HIPAA) and the Protected Health Information (PHI) portion of it that went into effect April 14, 2003, we cannot relinquish information without proper authorization.  Therefore, we will be addressing the concerns in question and responding directly to **** *****.
  
  I trust that the information provided will aid in resolving your concerns and want to thank you for the opportunity to assist you.  Should you have any additional inquiries, please do not hesitate to contact me by email at ***********@*******************
  
  Thank you for your concern.
  
  ***** *****
  Grievance Analyst I
  Medicare Complaints, Appeals & Grievances

  Customer response

  07/17/2023

  
  Complaint: ********
  
  I am rejecting this response because: the Anthem letter, dated 7-10-23 was a "cute" sidestep, citing HIPAA, when I had completed and sent Anthem's two pages Member Authorization Form 109931MUMENABS Rev. 10/18. on 7-1-23 to both Anthem and the Dayton BBB, and Anthem's promise to respond "directly to **** *****".  WHEN will Anthem respond to me, regarding the 12-21-22 dental claim?  On 10-5-22, Mirelle of Anthem advised me that my December dental claim would be paid.  Anthem's subcontractor, Liberty Dental's ******** in California, on 3-8-23, advised me that THIS CLAIM WILL BE PAID, ALSO THAT MY DENTAL RECORD WILLBE CORRECTED TO AVOID REPETITON OF THIS TYPE OF PROBLEM IN THE FUTURE.  On 6-7-23, ***** * of Texas, at Anthem, advised me that ******** had LIED to me on 3-8-23.  On 7-13-23, **** of Anthem advised me that my 12-21=22 dental claim will be paid, and that she will call me when the claim is paid.  PROMISES, PROMISES!  In the business of insurance, TRUST IS IMPORTANT, as is ETHICAL BUSINESS PRACTICES.  
  
  Sincerely,
  
  **** *****

  Business response

  07/26/2023

  Please be advise the member needs to fill out part B of the authorization giving the BBB permission to appeal on their behalf. Until we get a completed authorization we cannot review the members complaint. 

  Customer response

  08/02/2023

  Consumer called BBB with there response. 

  What are you wanting further filled out in Part B? There is nothing more that I can provide other than my spouse which is on there. You are just stone walling the situation. 

  Business response

  08/04/2023

  August 4, 2023
  Better Business Bureau of Dayton/Miami Valley, Inc.
  Attention: ******** *.
  ** **** ****** ******* ***** *** ******* ** *****
  VIA Portal Upload
  Member Name: **** *****
  Re: Medical and Dental Claims
  BBB File No.: ********
  Dear BBB:
  This is in response to your correspondence dated July 6, 2023, regarding the above referenced member.
  Due to federal laws pertaining to the Health Insurance Portability and Accountability Act (HIPAA) and the Protected Health Information (PHI) portion of it that went into effect April 14, 2003, we cannot relinquish information without proper authorization. Therefore, we will be addressing the concerns in question and responding directly to **** *****.
  I trust that the information provided will aid in resolving your concerns and want to thank you for the opportunity to assist you. Should you have any additional inquiries, please do not hesitate to contact me by email at ***********@*******************
  Thank you for your concern.
  ***** *****
  Grievance Analyst I
  Medicare Complaints, Appeals & Grievances

*Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business. ↩