Q: I desperately need your help with Anthem Blue Cross. Almost two years ago, I underwent emergency spinal surgery after an accident \u2013 it was medically urgent to prevent permanent damage.<\/p>\n
My health insurance company, Anthem Blue Cross, paid the hospital, ICU stay and anesthesiologist without issue. But it has denied the $18,926 surgeon\u2019s fee, claiming it lacked authorization from its third-party partner, Carelon.<\/p>\n
Here\u2019s the maddening part: Carelon repeatedly states that \u201cno authorization is needed\u201d for this emergency procedure. Anthem and Carelon refuse to talk directly, leaving me and my surgeon\u2019s office stuck in the middle, making over 80 phone calls to try and resolve this issue.<\/p>\n
Every time we follow Anthem\u2019s instructions, it rejects the claim weeks later for a new reason: \u201cmissing records\u201d (they misfiled them), \u201cwrong appeal form,\u201d or \u201cuntimely submission\u201d \u2014 even when we acted on its directives. We filed multiple appeals, including one Anthem specifically requested during a three-way call. They denied it anyway.<\/p>\n
The cruelest twist? Anthem imposes a strict two-year deadline to resolve claims. Our window slams shut in a few weeks. I\u2019m exhausted and terrified of being stuck with this bill. What can I do when the insurer and its own partner can\u2019t agree on their rules?<\/p>\n
\u2014 Hien Shields, Sunnyvale, Calif.<\/p>\n
A: After having emergency surgery, the last thing you should face is a 21-month odyssey through a bureaucratic maze built on contradictory demands and missing paperwork. Anthem\u2019s obligation wasn\u2019t just to process your claim \u2013 it was to provide clear, consistent guidance and ensure that its partners, such as Carelon, are aligned on policies for urgent care. Instead, they left you mediating a dispute between their own departments. That\u2019s inexcusable.<\/p>\n
Under state and federal law, Anthem was obligated to cover emergency services deemed medically necessary without requiring prior authorization. When Carelon stated no authorization was needed, Anthem should have resolved the internal disconnect immediately.<\/p>\n
Losing records, giving conflicting instructions and ignoring appeals until deadlines nearly expired are a problematic business practice. California law requires timely responses (typically 30 days for claims, 60 for appeals).<\/p>\n
While you did nearly everything right \u2013 documenting calls meticulously, enlisting your provider\u2019s help and persisting through appeals \u2013 starting your written paper trail earlier could have accelerated things. After the first denial, sending a formal appeal creates a better record. Always get names and reference numbers from every call. If a rep promises action, ask for an email confirmation.<\/p>\n
When companies stonewall, escalate to executives. I publish contacts for exactly this reason: Here are the names, numbers and emails for Anthem Blue Cross<\/a>.<\/p>\n I contacted Anthem several times on your behalf. In a stunning but telling twist, your surgeon\u2019s office zeroed out the $18,926 charge shortly after my inquiry. While I\u2019m relieved for you, this resolution is bittersweet. It underscores a grim reality: Providers sometimes abandon valid claims because fighting insurers is more costly than the debt itself.<\/p>\n Christopher Elliott is the founder of Elliott Advocacy<\/a>, a nonprofit organization that helps consumers solve their problems. Email him at chris@elliott.org<\/a>\u00a0or get help by contacting him at the nonprofit\u2019s site<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"Q: I desperately need your help with Anthem Blue Cross. Almost two years ago, I underwent emergency spinal…\n","protected":false},"author":2,"featured_media":224103,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[34],"tags":[752,14895,72,811,115455,103,397,396,61,60,166,115456,4674,14898,14899,115457,6490],"class_list":{"0":"post-224102","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-healthcare","8":"tag-advice","9":"tag-bay-area","10":"tag-business","11":"tag-california","12":"tag-coffee-break","13":"tag-health","14":"tag-health-care","15":"tag-healthcare","16":"tag-ie","17":"tag-ireland","18":"tag-lifestyle","19":"tag-problem-solved","20":"tag-retail","21":"tag-santa-clara-county","22":"tag-south-bay","23":"tag-sunnyvale","24":"tag-things-to-do"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/224102","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/comments?post=224102"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/224102\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media\/224103"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media?parent=224102"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/categories?post=224102"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/tags?post=224102"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}