Health Plan’s New Dirty Trick


By John Wallace, MD
President of IEPC

Anthem Health plan initiated a practice of “no pay” for ER diagnostic E and M code 99285 for discharged ER patients sometime in 2020. That the Health Plan’s new Dirty Trick, simply not pay anything. Ironically, while the health plans are committing fraud, they are accusing the doctors of fraud.

Anthem has referred Emergency Physician (EP) groups to their Special Investigations Unit and placed them under prepayment review to justify its behavior which is contrary to California Health and Safety Code Section 1371.35(a). California law requires health plans to pay the uncontested portion of each claim where emergency services have been rendered. Anthem argues they are not required to pay the claim, because of billing fraud, or alternatively that these are incomplete claims since there is a disagreement about the coding of the claim. However, a disagreement over coding, or even miscoding, does not constitute fraud or misrepresentation. Nor does including other services conducted in conjunction with a visit (eg. billing for an EKG read along with billing for the medical workup of a cardiac case), described as inappropriate unbundling, constitute fraud. The EP groups not coding to Anthem’s satisfaction is not fraud.

Similarly, a complete claim under 28 CCR § 1300.71 requires there to be sufficient information provided for the plan’s claims adjudicator to determine the plan’s liability. It contemplates that the physician will submit their information and the plan will independently determine their liability. In no way does it require that the physician code the claim to the satisfaction of the payer to be considered a “complete claim.”

The arguments made by Anthem that EP groups are submitting fraudulent or incomplete claims are preposterous.

Anthem appears to be targeting small independent EP groups vs large multi-hospital groups and including patients in coverage categories regulated by all: DOI, DMHC, ERISA and Medicare Advantage. Although, there is one large group that reported nonpayment by Medicare Advantage claims. The pattern of nonpayment is feared to be spreading from California small groups to a national trend and attack on emergency physicians.

While Anthem and Government regulators have met with impacted groups and California ACEP multiple times, the result has been extremely frustrating, and no payments have been issued for services already rendered. Legal recourse for OON Groups is available through litigation (see below case details) and multi-party lawsuit has been assembled. In network Groups are precluded by their contracts from litigating and instead must arbitrate. Anthem’s longstanding tactics to force ER Groups to accept low in network rates and efforts to avoid payment for ER services already rendered were chronicled in the March 2018 IEPC Newsletter: David vs Goliath: IEPC challenges Health Plan behemoth Anthem Blue Cross regarding unfair Provider contracting practices.

What can emergency doctors do? Groups can fight back against health plan dirty tricks by joining the lawsuit or submitting data to California ACEP. No all groups can afford litigation, but data sharing is essential in this fight.

Plaintiffs vs. BLUE CROSS OF CALIFORNIA, Case no: 22STCV05625
Legal Counsel: Buchalter and Associates

Emergency Department Billing Data Collate all Level 5, 99285
discharged with zero pay from Anthem.
Submit to California ACEP executive director, Elena Lopez Gusman

Thanks to Elena Lopez Gusman, California ACEP Executive Director in assisting with the preparation of this article

To view the full July 2022 newsletter click here.