You may be aware of the Louis Peterson v. United HealthGroup lawsuit that was decided by the Eighth Circuit Court of Appeals recently. That case involved how United HealthGroup conducted offsetting and cross-plan offsetting of non-participating provider claims.
As a result of this case, Anthem has made the decision to cease the practice of offsetting and cross-plan offsetting for non-participating, or out-of-network, provider claims in all Anthem States, but will continue offsetting and cross-plan offsetting for participating, or in-network, provider claims and is updating its Administrative Services Agreements to improve the language in the provisions that address offsetting and cross-plan offsetting.
The notice below describes the changes being made to the Administrative Services Agreement and should be considered to take effect immediately. Any discrepancies will be addressed through the full amendment that will be provided at your renewal on or after October 1, 2019.
Outlined below are a couple more key highlights:
- Anthem only offsets or cross-plan offsets to recoup overpayments when the payment was made directly to the provider, rather than the member. Because Anthem’s general practice is to pay the member when a non-participating provider is used, offsetting of out-of-network provider claims is limited. Only about 5 percent of overpaid claims have been paid to non-participating providers.
- It’s important to note that the appeals court’s decision does not apply to offsetting or cross-plan offsetting with respect to participating, or in-network, providers. Our contract language with participating providers expressly allows for offsetting and cross-plan offsetting and limits the rights of such providers to balance bill members. The overwhelming majority – approximately 95 percent – of Anthem’s offsetting and cross-plan offsetting of claims are for in-network providers
You can read Anthem’s Notice Here: Offsetting Amendment Notice