Running into a lot of level of care (LOC) related denials from Anthem, Inc at your addiction treatment center? You’re not alone. 

While residential treatment, intensive outpatient and partial hospitalization rank as some of the most commonly denied types of behavioral health care, Anthem, Inc is in a class of its own for issuing denials to behavioral health patients and providers.

Who is Anthem, Inc? What are their average denial rates and how do they compare to the industry average? What levels of care are most likely to be denied by Anthem, Inc? What can your addiction treatment center do to fight back against behavioral health care denials from Anthem, Inc? 

Today, we’ll answer all of these questions and uncover what Anthem, Inc’s denial rates mean for your addiction treatment center’s billing operations. 

Who is Anthem, Inc? Why Are They a Top Insurer for Would-Be Addiction Treatment Patients? 

Anthem, Inc, the largest for-profit federation member of the Blue Cross Blue Shield (BCBS) Association, with over 45.1 million members and counting in the United States. Simply put, you’ll see Anthem, Inc in your billing department again and again because they own such a large share of the insurance marketplace.

What Are the Average Denial Rates at Anthem, Inc? Are They Higher Than Average For Addiction Treatment Centers?  

There’s no way to sugar coat it: Anthem constantly denies all types of health coverage at twice the rate of the industry average. 

In 2019, Anthem’s denial rate was 35%. The average rate of denials in the industry currently hovers around 17%. Anthem has been repeatedly fined millions of dollars for reneging on their financial responsibility to patients and providers in variously creative ways, with denials figuring largely in this pattern. 

A report on Health Payer Intelligence elaborated on those same 2019 findings, calling out specific Anthem brand names with the highest denial rates: 

…[S]even payers that had the highest denial rates, all of them Anthem and Blue Cross Blue Shield (BCBS) companies: BCBS of Tennessee, Anthem BCBS of Georgia, Anthem BCBS of Maine, Anthem BCBS of Ohio, Anthem BCBS of Virginia, Anthem BCBS of New Hampshire, and Anthem BCBS of Kentucky.

What is Anthem Inc’s Denial Rate for Behavioral Health Care and Addiction Treatment?

The statistics on Anthem’s denial rates for behavioral healthcare are, frankly, galling. 

A CBS investigation in 2014 uncovered a claim denial rate for mental and behavioral health care exceeding 90% at Anthem. A study in New Hampshire found that Anthem Blue Cross and Blue Shield (along with top competitors Cigna and Harvard Pilgrim) frequently deny opioid treatment at rates between 9.5% - 28.3%. 

It’s currently being decided in court whether these extraordinary rates of denial constitute a violation of mental health parity laws. 

Why Are Anthem’s Addiction Treatment Denial Rates So High?

Anthem, Inc is known to use several different mechanisms for denying addiction treatment claims. USA Today reported that many experts blame new documentation requirements, overly conservative prior authorization rules and Anthem’s insistence that medical professionals - rather than support staff - spend time on the phone defending claims to Anthem representatives for the high denial rates at Anthem, Inc. 

For behavioral health providers and addiction treatment centers, however, the problems are often centered around level of care concerns. 

Anthem Inc’s Denial Rates are Tied Up in Level of Care Disputes for Addiction Treatment Providers

It’s well known that Anthem frequently denies physician requested inpatient care and offers a lower level of care, like outpatient care, instead. If you look at the Health Insurance Exchange Public Use Files, and the Transparency in Coverage PUF in particular, you’ll see that about 25% of Anthem’s denials can be traced to exclusions. Another 9% are based on the fact that a required referral was not secured prior to the service. However, you’ll also notice that the majority of denials are listed under “other.”

Independent investigators have discovered that the most common cause for denial outside of medical necessity usually centers around quibbles with the level of care requested. Based on the data we have available, it seems likely that Anthem’s denial rates for addiction treatment are most often tied to level of care issues. 

Tired of Dealing With Level of Care Denials From Anthem, Inc at Your Addiction Treatment Center? We Can Help.

You’re not the first addiction treatment professional to get fed up with billing struggles. 

BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States. Even better, we’re not health care generalists.  We only work for behavioral health providers like you.  

Let our team of specialists handle it all: 

• Verification of Benefits

• Utilization Review 

• Billing and Collections 

• Patient Responsibility

• Denials and Appeals (including level of care denials)

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.