The California Hospital Association is involved here with stating there had been several complaints from providers. The story states that they have more denied claims from Blue Cross than all the other carriers combined. Mental health again is getting the short end of the stick. Sharp Hospital says that patients are not getting access to proper care.
Two years ago is when the hospital began to change how it reviewed claims, and hmmmm let me see that’s when the new business intelligence algorithms could have come into play, right? That’s what usually happens with insurers and it’s algorithms that give the yes or the no based on analyzing data. About one third of the days submitted have been refused and now an increasing number of doctors are refusing to see patients. BD
SAN DIEGO — San Diego’s largest private providers of mental health services are having problems with California’s second biggest HMO.
These hospitals complain Anthem Blue Cross refuses to cover a high percentage of hospital stays for psychiatric emergencies.
Health care providers complain the situation is affecting access to care.
We now have more denied days from Anthem Blue Cross than any other payer," Dr. Plopper said. "We have more hospital stays here that include denied days by the insurance company, than all of our other insurance companies combined."
Medical director Tom Flanagan used to sit on one of Anthem Blue Cross’s medical advisory committees. But he resigned two years ago, when he noticed the insurer began to deny care for a high number of his patients.
Sharp has recently appealed 366 hospitalization days that Anthem wouldn’t pay for. The company reversed its decisions on only six of those days, a reversal rate of 1.6 percent.
Sharp said the average reversal rate for all of its insurers is 53.8 percent.
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