Anthem Health Plans has been instructed to pay back 446 Virginians a total of $216,964. These individuals, who filed claims between 2021 and 2024, had been charged a copay for contraceptives deemed necessary by their doctors, according to a complaint filed following the Bureau of Insurance’s investigation. Virginia law mandates that insurance companies cover preventive services without charging copays.
Anthem identified the overcharges as a system issue. Cigna Healthcare was ordered to reimburse 457 customers approximately $404,000. The company had incorrectly informed customers that it would reduce the amounts it paid based on the level of Medicare coverage patients had, which is against Virginia state regulations.
These orders come as part of broader regulatory efforts to ensure insurance companies comply with state laws protecting consumers from improper charges. A medical billing expert offers tips on what to look out for when filing health insurance claims and what to do if your bill is wrong. “Forty percent of all medical bills have some form of error.
It doesn’t mean that every time it’s a financial impact, but a lot of times it is,” said Scott Speranza, CEO & Founder of HealthLock, a company that tracks health insurance claims for its customers and fights billing battles on their behalf. Speranza points out that overcharges, fraud, and claim denials result in significant financial losses for consumers. He notes that the technical complexities between providers and carriers can lead to billing inaccuracies.
“It’s a very complicated transaction between the provider and the carrier. It’s actually more complicated, probably than the IRS tax system,” Speranza said. “If anything goes wrong in that process, you get a denial or a partial denial.”
Speranza advises individuals to be vigilant and proactive when it comes to their medical bills.
He suggests understanding what services are being provided, what you are being billed for, and whether it is “in-network” or “out of network.” If you receive a questionable bill, contact your provider and follow up with your insurer to resolve the issue. However, be prepared to spend significant time on the phone.
Insurance overcharges prompt reimbursements
Speranza also encourages patients to appeal denied claims, noting that while many claims are denied, only 1% of people actually appeal those decisions. “It’s complicated, but you can do it,” he said. Cigna and Anthem, two healthcare insurance giants, will have to reimburse hundreds of overcharged Virginia customers more than $620,000.
According to a Bureau of Insurance investigation, Anthem erroneously charged a copay to customers for a brand-name contraceptive their doctors deemed medically necessary with no generic alternative. In Virginia, insurance companies are required to cover preventive services without charging co-pays. The Virginia State Corporation Commission ordered Anthem to pay back 446 Virginians who filed claims between 2021 and 2024, totaling $216,964.
The commission also ordered Cigna Healthcare to reimburse 457 customers approximately $404,000. The investigation found the company had told customers that it would lower the amounts paid based on the level of Medicare coverage patients had, a practice prohibited by the state of Virginia. Health insurance companies have faced public scrutiny over the last few months following the death of UnitedHealthcare CEO Brian Thompson.
Thompson’s death, which occurred while he was attending a conference with UnitedHealthcare investors, sent shockwaves and sparked criticism nationwide about how the industry treats customers. UnitedHealthcare, the country’s largest insurer by market share, has been the subject of lawsuits for allegedly denying claims to maximize profits. Late last year, a KFF survey found that roughly 6 in 10 insured adults have experienced problems with their health insurance.
These issues range from denied claims to preauthorization delays and denials. An investigation revealed that a hidden industry makes money by rejecting doctors’ payment requests, known widely as prior authorizations. As previously reported, a ProPublica investigation found that a majority of American insurance companies hire EviCore to provide coverage to 100 million consumers.
EviCore reportedly uses an algorithm backed by artificial intelligence that insurance insiders call “the dial.” This algorithm system can be adjusted, ultimately leading to higher denials of preauthorization claims. The recent orders against Cigna and Anthem highlight ongoing issues in the healthcare insurance industry, particularly around how companies handle preventive services and preauthorization processes. As scrutiny of these practices continues, affected consumers in Virginia may soon see some financial redress.
