Valley Health sues Anthem for $11.4 million in overdue payments | Winchester Star


WINCHESTER – Valley Health System is suing Anthem Blue Cross Blue Shield, now known as Elevance Health, for $11.4 million in delinquent payments, according to a press release.

The lawsuit was filed Thursday in Winchester Circuit Court. It includes two counts: breach of contract and violation of the Virginia Ethics and Fairness in Carrier Business Practices Act.

Mark Nantz, president and CEO of Winchester-based Valley Health, said the decision was “a last resort” and follows two years of attempts to resolve refunds Valley Health says are owed by Anthem, which is the largest health insurer in Virginia. .

“We incurred the cost, we performed the service and we didn’t get paid,” he said Thursday. “We called on them. Some of these accounts are over 2 years old.

Valley Health, which operates six hospitals including Winchester Medical Center, has “worked in good faith to quietly resolve significant reimbursement issues with Anthem,” the statement said, but “gross delays in payment for healthcare services provided to its members” forced his hand. .

“Anthem left us no choice but to take legal action,” Nantz said in the statement.

“We will not accept that Anthem continues to avoid payments due to our healthcare system, which limits our resources to provide the care that our patients and their members pay for, expect and deserve.”

Valley Health tried for many years to work with Anthem to resolve “its claims processing and payment flaws,” the lawsuit reads, and devoted “hundreds of employee hours” to meetings, calls, searches and “responding to an endless stream of repetitive and unnecessary questions and data requests, but to no avail. »

The suit goes on to say that this is not an isolated incident.

“In March 2022,” the suit states, “the Georgia Insurance Commissioner’s Office fined Anthem’s Georgia subsidiary multi-million dollars for, among other misconduct, improper claims-adjudication practices and violations of Georgia Prompt Pay Act requirements to pay health care providers. .”

The Maine Department of Insurance is also investigating and reviewing the payment practices of Anthem’s Maine subsidiary.

Citing media reports, the suit says Anthem owes more than $300 million in unpaid claims to VCU Health of Richmond and its Maine subsidiary owes $70 million to a hospital system in Portland, Maine.

The lawsuit was filed by Kevin M. Rose, Michael W. Sharp and Mary Margaret Hawkins of BotkinRose PLC in Harrisonburg.

Valley Health recently raised concerns about its economic outlook after 2½ years of the COVID-19 pandemic, which has resulted in drastic staff shortages, amid the nation’s highest inflation rate since 1982.

The statement also referred to “continued losses in the treatment of Medicare, Medicaid and self-paid patients” while calling out Anthem for recently announcing record profits.

A fact sheet provided by Valley Health on Thursday further explains why the health system has filed a lawsuit, stating, “As the insurer continues to raise premiums and enjoys record profitability, every dollar won by Anthem/Elevance withholds from Valley Health compromises access to sustainable, high-quality health services available throughout the Shenandoah Valley.

Anthem/Elevance made $6.1 billion in profits in 2021 alone, which Valley Health says is up 30% from 2020.

“Meanwhile, healthcare systems are experiencing record losses,” says Valley Health.

According to Valley Health, its Anthem reimbursements are behind schedule by $2.6 million in fiscal 2019, $2.9 million in 2020, and $9.5 million in 2021. As of September 2022, 11 .4 million are due.

Meanwhile, he states that Anthem’s growing profits amounted to $4.8 billion in 2019, $4.6 billion in 2020, and $6.1 billion in 2021. In June 2022, he said reached $3.5 billion in profits.

Additionally, it says Anthem/Elevance owns 43% of Virginia’s health insurance market, allowing it to “force health systems to accept gross breaches of contract like this.”

Valley Health is far from alone in dealing with non-reimbursement of services, Nantz said Thursday. He explained that while Valley Health makes its judgments regardless of what is happening elsewhere, it knows that other health systems around Virginia are experiencing the same kinds of issues.

Information provided by Valley Health also lists Indiana and Wisconsin as states with health systems or state regulators that fined the insurance provider.

Conversely, Nantz said, Valley Health doesn’t have these issues with any other insurance provider.

“All the other payers we work with, we don’t have anything like that,” he said.

Valley Health renewed its three-year deal with Anthem in January 2021 after lengthy contract negotiations. This allowed Valley Health to avoid ending its relationship with Anthem, “which would have been very disruptive to Anthem members,” the lawsuit states.

In a statement Thursday night, Anthem/Elevance called Valley Health’s claims exaggerated.

“We are aware of the lawsuit that has been filed and are reviewing it,” the statement said. “We want to be clear that this action does not affect access to care in any way, and Anthem Blue Cross Blue Shield members can continue to receive care at Valley Health. …

“With respect to some of the specific claims made, we believe they have been inflated based on inaccurate and incomplete data,” the statement continued. “It is standard industry practice to review requests for medical services to ensure they are coded and billed appropriately. Anthem Blue Cross and Blue Shield in Virginia strive to process claims as quickly as possible and in accordance with our agreements, while verifying billing accuracy, which requires the cooperation of our vendor partners.

The statement said the insurance provider will continue to work with Valley Health to resolve the issue as quickly as possible.

Valley Health, too, “will continue to do our part to serve our community and ensure patients have access to providers and services in our health system,” Nantz said in the statement.

“But we must hold Anthem – one of the nation’s largest health insurers and responsible for much of Valley Health’s revenue – accountable for the adverse effects of their late payments that ultimately impact our ability to maintain quality community health services.”

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