The Georgia insurance commissioner is hitting Anthem Blue Cross Blue Shield with a $5 million fine—the largest in agency history— over claims processing errors.
Anthem failed to comply with state laws on a number of occasions between 2015 and 2021, insurance commissioner John King (R) announced Tuesday. Those included improper claims settlement practices, violations of the state Prompt Payment Act, a lack of timely responses to consumer complaints, inaccurate provider directories and provider contract loading delays, according to the regulator.
"My number one priority is protecting Georgia consumers," King said in a news release. "After numerous complaints made to our office regarding the operations of Blue Cross Blue Shield from individuals, physicians, hospitals and others from around the state, I instructed my staff to conduct an extensive examination into the carrier's practices."
Anthem Blue Cross Blue Shield could also incur more penalties if it does not adhere to benchmarks set out in the insurer's corrective action plan, King said.
In a statement, Anthem Blue Cross Blue Shield said the investigation mainly focused on a database system no longer in use and that the company is working to process and pay claims as quickly and efficiently as possible in accordance with provider agreements and state regulations.
"As the department is aware, we worked diligently to address these challenges," the company said. "We have since migrated to a new platform with the goal of improving accuracy and transparency. We are dedicated to those we serve and partner with, and we believe the recent enhancements we have made will create an improved overall care provider experience."
Before the implementation of a replacement provider database system last year, the insurer was out of compliance with timeliness requirements on and off since 2018, according to Georgia.
The most common errors providers cited were in-network claims being processed as out-of-network and the insurer rejecting claims for unknown reasons. Both categories of problem were largely due to system coding errors that also led to incomplete and inaccurate claims data submissions, the insurance department found.
The corrective action plan dictates that Anthem Blue Cross Blue Shield develop a new process for dealing with provider complaints, pay claims within the statutory time lines, upload provider contracts in a timely manner and submit monthly reports on its progress. The insurer's day-to-day business practices will be monitored to ensure compliance with the order.