Patient sues Anthem Blue Cross over liver transplant

[herring_RN, ASN, BSN]

Patient sues Anthem Blue Cross over liver transplant

...Ephram Nehme was gravely ill when Anthem Blue Cross of California agreed to pay for a liver transplant his physician said he needed to survive. Then, his condition went downhill fast.

The news from his doctor was bad. The word from his insurer was worse.

Nehme's doctor told him he could die waiting for an organ in California and urged him to go to Indiana, where the waiting list was shorter. But Anthem Blue Cross said no. It would not pay for a transplant in Indiana....

...Nehme, a Lebanese immigrant with a rags-to-riches story, could afford to buy himself a new lease on life and did -- going to Indiana and paying $205,000 for a liver transplant there.

But he remains angry with Anthem and sued the company, accusing it of putting its bottom line ahead of his medical needs.

"I hope I can change it for other people," said Nehme, 61, who runs produce markets in the San Fernando Valley and Simi Valley. "If somebody doesn't have a nickel in his pocket, what happens? He's dead."

The case offers a rare glimpse into the life-and-death decisions insurers make behind closed doors and illustrates one of the most emotional questions in healthcare: Who should decide what is best for a patient -- doctors or insurers?...

http://www.latimes.com/business/la-fi-transplant7-2009oct07,0,1324752,full.story

[Pierrette]

Who should decide what is best for a patient -- doctors or insurers?...

Or, as it appears, the government?

https://allnurses.com/social-health-care/largest-denier-health-429993.html#post3906423

[NRSKarenRN, BSN, RN]

yep, anthem is a big denyer of claims

percentage of claim lines reduced to $0 by edits

anthem bcbs 7.33%

medicare 1.40%

on what percentage of records does the payer’s allowed amount equal the contracted payment rate?

anthem bcbs 72.14%

medicare 98.12%

along with cigna, anthen is worst to deal with according to our home care managed care billing manager.

other companies, you must have bills submitted within 60-90 days in order to get paid....while medicare allows you 18 months to submit final bill for payment. have staff overturner, someone forget to get authorization ---bill rejected. no preauth with traditional medicare!