Anthem Blue Cross Audit Highlights Recovery Management Challenges

Anthem Blue Cross (Anthem) has encountered significant challenges in managing the recovery processes tied to its contract with New York State's Department of Civil Service. The contract spans from January 2019 to May 2024 and retroactively includes certain claims from January 2018. A recent audit uncovered that Anthem failed to remit over $19.3 million in hospital claim overpayments due to Civil Service, showcasing lapses in its recovery management.

The New York State Health Insurance Program (NYSHIP), administered by Civil Service, is one of the largest public sector health insurance programs in the U.S., serving approximately 1.2 million employees and their dependents. Under the Empire Plan, a pivotal component of NYSHIP, Anthem is tasked with handling the Hospital Program, which covers both inpatient and outpatient services. Despite its responsibilities, Anthem faced discrepancies in claims handling, with $15.1 million in identified overpayments not recovered due to incorrect time frame applications, and $4.2 million in recoveries left untracked.

Following the audit by the Office of the State Comptroller, Anthem refunded $7.3 million to Civil Service, leaving about $12 million under further review. The audit also pointed out contractual limitations between Anthem and hospitals that impeded the investigation into $55.8 million of potentially erroneous claim payments. This situation emphasizes the critical need for stringent oversight and regulatory compliance in managing recovery processes to ensure financial accountability. For further information, contact Audit Director Christopher J. Morris at (518) 474-3271 or email audittips@osc.ny.gov.