The California Medical Association (CMA) has submitted a formal complaint with the California Department of Managed Health Care (DMHC) regarding Anthem Blue Cross’ ongoing pattern of denying payment for emergency department services in violation of California law.

Although California law states payment for emergency services may only be denied if a plan determines the services were not performed, Anthem has adopted a policy under which it routinely denies claims that include high level emergency department evaluation and management (E/M) services. As a result, Anthem is not only refusing payment for the emergency E/M service, but also failing to reimburse the remaining uncontested portion of these claims. Anthem is also failing to provide an accurate and clear explanation of the reasons for denial, and subjecting physicians to unnecessary and unreasonable requests for patient medical records beyond what is needed to determine payor liability.

Given the dollar value of denied claims and the impact of the denials on physicians’ ability to provide emergency care, Anthem’s practice may also represent an unjust payment practice by unnecessarily delaying payment for complete and accurate claims.

“Anthem’s denials have placed significant undue financial hardship on emergency physicians throughout California who, for the last two years, have served on the front lines caring for COVID-19 patients,” wrote CMA CEO Dustin Corcoran in a letter to DMHC. “Anthem cannot be allowed to profit from unpaid emergency services provided to its enrollees. DMHC must take swift action to ensure that Anthem complies with California laws designed to protect health care consumers and providers.”

CMA is urging DMHC to formally investigate and take appropriate enforcement action to require Anthem to promptly reimburse physicians for denied emergency room services with interest.

For more information, see CMA’s letter.