[Harrison]

Anthem Blue Cross and Blue Shield:

Big, Bad, and Loaded for Bear

My good friend who works for a health insurance company often asks a rhetorical question: "You don't believe that health insurers are the evil empire, do you?"

I never thought about it, until I squared off against Anthem Blue Cross and Blue Shield.

Anthem is big

March 2007: A patient in California tells me that Blue Cross of California has been gobbled up by Anthem BC/BS.

What is going on here?


Anthem is bad

July 2007: I am in Calfornia for a speaking engagement, and I pick up the Hayward newspaper. I see the following headline:

"California didn't try to collect Anthem Blue Cross fine."

In 2006, the California Department of Managed Healthcare levied a fine of $200,000 against Anthem for one unlawful case of "recission." Here is how recission works. When you become expensive (i.e., get sick), Anthem's recission experts get to work. They go back to your original application, and go over it with a fine-tooth comb, looking for an offense/glitch/mistake that would enable them to cancel your coverage.

Anthem did this to 1,770 insured and ill people between 2004-2007, and California imposed an additional fine of $1 million. California has never collected any of this money.

The intrepid reporter from the Hayward Daily Review asks the Director of the Department of Managed Healthcare, "Why haven't you collected any of this money?"

The Director replies that Anthem has the right to contest every one of the 1,770 cases in court. Since Anthem has so many recissions, his department will be tied up in the courts for many years, and no fine will ever be collected.

If you become big enough, you will overwhelm the law with the very weight of your offenses. In other words ... you win.

Anthem is loaded for bear

In September 2008, a very nice gentleman called me from Virginia. He wanted to get to Dr. Sugarbaker for the same lifesaving surgery that I had in 2005.

I went looking for successful lawsuits against Anthem. How did they win, what did they prove, what words did they use?

I happened across Dardinger vs. Anthem of Ohio. I found plenty of language to use. I also found the story of Esther Dardinger.

This was a tort case, on behalf of the estate of Mrs. Dardinger. Yes, the plaintiffs in these types of lawsuits are usually dead. She was forty-nine years old, and she suffered from brain cancer, which had metastized from the breast. Her doctor, who was Director of Neuro-Oncology at the local medical center, recommended that she undergo four treatments of IAC (intra-arterial chemotherapy), which delivers the chemotherapeutic agent directly to the brain.

Anthem approved, and paid for the first three treatments. These treatments dramatically shrank the brain tumors, and improved her symptoms.

When it came time for the fourth treatment, Anthem denied it. All of a sudden, this treatment had become "experimental."

The patient and her husband had no idea what to do. Appeals were filed by doctors, lost, shelved, ignored. All of the interested parties were told to "wait for our letter," "wait until we decide," "wait for our call." This went on for three months.

The final denial letter arrived two days after Esther Dardinger died.

Anthem's position during the trial? "The only mistake we made was paying for the first three treatments." How must it have felt for the widower to hear that?

The court threw the book at Anthem for their "reprehensible" behavior, and slapped them with a $20 million fine.

Apparently, Anthem didn't learn from this case, because they were about to beat me with the same big stick.

Anthem spits in my eye

I will spare you the gothic novel that was my Anthem BC/BS of Virginia case. Suffice it to say that for two weeks they had a half-dozen of us on the ropes, losing sleep, writing letters all night long.

I have won forty-three appeals by assuming that health insurers will pay if I can prove that ...

• They have paid for it twenty-two times before.
• Their in-network doctors have no expertise with this disease.
• Their in-network doctors have made mistakes which could be fatal.
• Hundreds of peer-reviewed articles document good outcomes.
• I can find all of their most secret, highest-level insiders -- and their fax numbers.

... they will pay.

Not Anthem. In this case, they adopted a posture of, "We will deny all appeals, regardless of the merits. No approvals, ever. Just try and stop us. We spit in your eye."

First, Anthem tells my helpee that he has to go to an unqualified surgeon who is "in-network." That is standard.

Next, Dr. Sugarbaker's office finagles with Anthem until they approve the hospital ($150,000), but not the surgery ($25,000). This step is standard, and it always gives me a wry chuckle. What use is the hospital without the surgery? Didn't anyone tell Anthem that he is going to the hospital FOR a surgery?

At this point, I deploy the seventy-eight-page appeal, to get Anthem to approve the surgery, and sign the single-case contract with Dr. Sugarbaker's office. Here is where Anthem veers completely off the usual path. Instead of responding to the mountain of proof with a willingness to negotiate, they punish us by taking away the approval for the hospital. The patient is worse off than he was to begin with; he now has nothing.
Anthem justifies "taking back" their approval in two ways:

"We suddenly figured out that this treatment is experimental."
"We never approved it in the first place." (Even though we have copies of the approval letter.)

We supply cases where Anthem paid before. Anthem says that none of our precedent applies, because they those cases were in different states. So, Dr. Sugarbaker's office finds a case in Virginia where Anthem paid. Anthem say that they need "more cases in Virginia." They won't say how many cases would add up to an approval.

Dr. Sugarbaker's office finds two more Virginia cases where Anthem paid. Anthem says, "We will do everything in our power to find the differences between these cases and the current case."

Does this look like a good faith effort to provide safe and effective lifesaving treatment, or a no-holds-barred attempt to deny?
We kept on writing, they kept on spitting.

Finally, Ilse at Dr. Sugarbaker's office managed to maneuver Anthem into reinstating the approval for the hospital. The patient had to pay out-of-pocket for the surgery.

People say, "How can they do this? Can't you sue them?" Sure, go ahead and sue them ... but you probably won't win unless you're dead. Or should I say until eight years after you die, because that is how long it will take to wend its way through the courts.

Did they persist in denying this treatment, with no good reason for doing so? Was it deliberate? Was it evil? I leave it for you to judge. All I know is that it almost did me in.

The patient in question had his surgery with Dr. Sugarbaker today. I think back, as I always do, to my own surgery in 2005. I trust that, in four years, he will be as healthy as I am today. That he will be transformed by the experience, as I was. And that he will know, as I do, the sweet satisfaction of helping and being helped.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

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