Anthem Plays Dirty, Women’s Center Says

     FRESNO, Calif. (CN) – After paying a women’s medical center $295,000 for covered blood tests, Anthem Blue Cross decided it wanted the money back, so it took it – illegally – from other unrelated claims, the medical center claims in court.
     Advanced Women’s Health Center, of Bakersfield, sued Anthem Blue Cross Life and Health Insurance Co., in Federal Court.
     “Defendant has unilaterally declared that sums it previously paid to plaintiff, knowingly and voluntarily, can be recouped by defendant and it has engaged in the unlawful self-help method of physically taking funds from the plaintiff on other, unrelated health plan claims of plaintiff’s other patients under other/different health plans,” the Women’s Health Center says in its lawsuit.
     The money in question was paid in 2010 and 2011 for claims submitted by the health center, an in-network provider, for blood tests on its patients and medical services related to the tests. Anthem acknowledged that the tests were necessary and paid the claims under its 2010 and 2011 plans, the center says in its complaint.
     But after consulting with its corporate parent, WellPoint, Anthem decided to take back the money it had paid to all California medical providers for those blood tests and related medical services. WellPoint had all of its Blue Cross Blue Shield entities across the country try to take back the same payments, according to the complaint.
     “The various Blue Cross Blue Shield entities throughout the United States have taken similar approaches in seeking recoupment. One approach is to unilaterally – and retroactively – declare the subject blood tests and services to be ‘experimental’ or ‘investigational’ because health plans typically exclude payments for tests or procedures that fall into these two categories,” the complaint states. “The second approach is to criticize the manner or method by which the tests and related medical services were billed by the medical provider.
     “Here, defendant Anthem has acknowledged that it never declared, decided, or communicated to anyone a belief or a coverage position that the tests or services were ‘experimental’ or ‘investigational’ during the time that it repeatedly, knowingly, and voluntarily paid for the tests and services. As such, realizing that it has no basis upon which to assert a lack of coverage under the applicable health plans, and knowing that it waived its rights by voluntarily and knowingly paying all of the claims, Anthem has taken the second approach, i.e., criticizing the manner or method of billing for the tests or medical services.”
     Anthem claimed in a letter that the health center’s billing method violated the California Business Code and that the center could face criminal penalties. Anthem ended its letter by stating: “We solicit any information which would contradict our findings, or alternatively, a proposed resolution.”
     The Women’s Health Center denies such violations. It claims that Anthem’s 2010 and 2011 health plans “have no provisions and do not otherwise indicate that covered claims can somehow be subsequently converted to uncovered claims by virtue of a state law or rule of conduct relating to billing procedures by doctors. As such, there is no authority in the subject health plans for Anthem to unilaterally declare here that previously paid claims are somehow not payable or not covered, or subject to repayment or recoupment.”
     To take back its money, Anthem took money from new claims payments that it has acknowledged it owes to the health center under its 2013 health plans, according to the lawsuit. The current claims are for treatment for patients in 2013, and are unrelated to the payments Anthem made in 2010 and 2011, the health center says.
     “In addition, the current claim payments, being offset by Anthem, are payable under 2013 group health plans that are unrelated and different from the 2010 and 2011 Anthem Plans under which Anthem made payments to plaintiff, years ago,” the health center says.
     Although Anthem has no legal authority for its actions, its “unlawful taking of funds from the plaintiff is ongoing, causing severe financial and other disruption to plaintiff’s medical practice, all in violation of ERISA [Employee Retirement Income Security Act], PPACA [Patient Protection and Affordable Care Act], and California law,” the health center says.
     The Women’s Health Center seeks declaratory judgment that Anthem has no legal authority to reverse health plan determinations it made years earlier, and an injunction.
     The Women’s Health Center is represented by Robert K. Scott, of Irvine.

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