Monday, June 21, 1999
HMOs lose third of appeals
Anthem, United tops in Medicare reversals
The Associated Press
COLUMBUS — Two of Ohio's largest Medicare HMOs were among the worst in losing appeals over treatment that they denied to their members last year, according to federal documents.
Anthem Blue Cross and Blue Shield was ordered to pay for services in 40 percent of the cases in which it refused to provide or pay for care to members of its Medicare health maintenance organization, more than any other Ohio health plan, the Columbus Dispatch reported Saturday.
United Health Care of Ohio was reversed a third of the time.
Medicare, the federal health care program for those 65 and older and the disabled, contracts with 400 Medicare HMOs nationwide to provide policies that supplement the regular Medicare program.
When a Medicare HMO denies care or refuses to pay, a member, provider or medical supplier can appeal to the insurance company. If the company denies the appeal, an independent board selected by the federal government reviews each case.
Medicare overturned 53 of the 138 cases that Anthem denied last year and reversed 29 of the 87 cases United denied last year. The national average is about 20 percent.
Most of the Anthem cases that were reversed involved reimbursements sought by doctors and other health care workers, and claims for medical equipment and supplies.
“We're committed to the senior market,” said Lynne Gross, a vice president with Anthem.
She said Anthem is working to reduce the number of denials by educating doctors and members on how managed care works, tightening the bond between patients and doctors, and having the plan's medical director work more closely with Medicare's external review board.
Many claims denied by United Healthcare were cases in which it was not clear who was responsible for paying a bill, said Dr. Bruce Wall, medical director of the insurer's Columbus HMO.
The number of cases reviewed by the Center for Health Dispute Resolution is on the rise, the newspaper reported.
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