Author: Kendall Smith, MD | Chief Medical Officer & Chief Physician Advisor – PayerWatch & AppealMasters
10/3/24
Navigating the complexities of healthcare finance can be tough, especially when payers don’t play by the rules. For hospitals and health systems, part of a successful denial management strategy should involve reporting unfair practices to state insurance departments and regulatory bodies.
Why It’s Important
We’ve all been there—dealing with claim denials that just don’t make sense, or worse, patterns of unfair reimbursement practices that put your financial health at risk. It’s not just about fixing one claim—it’s about calling attention to payer behaviors that affect the entire healthcare system.
Take the recent case in California: Anthem Blue Cross was hit with an $8.5 million fine for mishandling claims disputes. That didn’t happen overnight; it took persistence from providers and regulatory action to hold Anthem accountable. Reporting these practices brings transparency and shows payers they can’t get away with unfair treatment.
What You Can Do
When a payer denies claims unfairly, the first move is to try to resolve it directly. But when that doesn’t work, don’t let their decision be the last word. Reporting payers to your state’s insurance department—or even federal regulators—can be a game-changer. By submitting a formal complaint with supporting documents, you raise a red flag that regulators can’t ignore.
Why It Works
When enough providers report the same issues, state departments take notice. They can launch investigations, impose fines, and even enforce policy changes. Anthem’s fine is just one example of how reporting can have real consequences for payers. And once a payer is on a regulator’s radar, they’re more likely to clean up their act.
Our Recommendation
At PayerWatch, we don’t just recommend reporting payers—we help you do it. We know the process can feel overwhelming, especially when you’re up against a large payer, but you don’t have to go it alone. Our team has the expertise to guide you through filing complaints and navigating the regulatory landscape.
We’ve helped health systems across the country hold payers accountable, resulting in better outcomes for both providers and patients. Don’t settle for unfair treatment. Let PayerWatch help you take a stand, protect your bottom line, and advocate for a more fair and transparent healthcare system.
