Latest news with #AnthemBlueCrossBlueShield
Yahoo
01-08-2025
- Health
- Yahoo
OhioHealth and Anthem extend contract negotiations into August, hope to reach agreement
Coverage for OhioHealth patients under Anthem Blue Cross Blue Shield has been extended as contract negotiations continue between the two heavy hitters in Ohio health care. More on OhioHealth, Anthem : OhioHealth patients covered by Anthem could lose coverage on Aug. 1 OhioHealth, the largest health system in Ohio and Anthem, one of the largest health insurance providers in the country, announced earlier this month that patients would be out of network with OhioHealth if they couldn't reach an agreement by July 31. That deadline has now been extended to Aug. 15. Representatives from both entities told The Dispatch that they are hopeful a deal will be reached before the new deadline. "We are continuing to provide care for our patients who are covered by Anthem and are optimistic we will have a new contract signed before the contract extension expires," a spokesperson for OhioHealth said in an emailed statement. A spokesperson for Anthem Blue Cross Blue Shield said they are "optimistic we will reach an agreement before that date." "Anthem members should continue to seek care at OhioHealth as they have in the past," the spokesperson said in an emailed statement. More information can and updates can be found on both the OhioHealth and Anthem websites. Medical business and health care reporter Samantha Hendrickson can be reached at shendrickson@ This article originally appeared on The Columbus Dispatch: OhioHealth, Anthem agree to new deadline for contract negotiations Solve the daily Crossword
Yahoo
01-08-2025
- Health
- Yahoo
OhioHealth and Anthem insurance reach agreement, keeping thousands of Ohioans covered
OhioHealth and Anthem Blue Cross Blue Shield insurance reached a multi-year agreement, meaning thousands of Ohioans across the state can stay covered in Ohio's largest health system. The entities on Aug. 1 announced the agreement was reached after alerting patients they could fall out of coverage just weeks ago in mid-July. The agreement continues "uninterrupted access" to care at all OhioHealth hospitals, facilities and physician practices for Anthem members in all health plans. That includes employer-sponsored, individual, Medicare Advantage and Medicaid health plan networks, according to both entities. 'We're glad to continue our long-standing relationship with OhioHealth,' said Jane Peterson, president of Anthem Blue Cross and Blue Shield in Ohio. 'It's about making sure people get the right care at the right time — care that leads to better health outcomes, more support for individuals' whole health, and ultimately lower costs for individuals, families and employers across central Ohio.' OhioHealth expressed similar sentiments. 'We're happy to have reached a new contract with Anthem, which ensures our patients can continue to receive the high-quality care they need without interruption or uncertainty,' said Carrie Harris-Muller, senior vice president and chief population health officer of OhioHealth. 'Our priority is, and will always be, improving the health of those we serve.' Anthem members with questions should call the Member Services number listed on the back of their Anthem ID card, Anthem said in a statement. This is a breaking news story and will be updated. Medical business and health care reporter Samantha Hendrickson can be reached at shendrickson@ This article originally appeared on The Columbus Dispatch: OhioHealth and Anthem insurance reach multi-year agreement Solve the daily Crossword
Medscape
22-07-2025
- Health
- Medscape
A Life on the Line and $250K in Debt Amid Insurer Denials
The diagnosis came just as Nathan Kirkland and his wife were preparing for the birth of their second child in April 2024. Tests showed Kirkland, then 35 years, had intrahepatic cholangiocarcinoma, a rare form of cancer that develops in parts of the bile ducts housed within the liver. Kirkland's only chance for a cure was a liver transplant, but his tumor was too large to meet the criteria for the surgery. 'Cholangiocarcinoma just isn't a cancer most people come out on the other side of,' Kirkland told Medscape Medical News . 'The doctor said to me, 'Don't plan on seeing your daughter born in a few short months.'' Kirkland and his family Devastated, but determined to fight, Kirkland started a chemotherapy regimen that month to help shrink the tumor. To improve his chances for a liver transplant, his oncology team also recommended a noninvasive procedure, known as a histotripsy, that uses high-intensity sound waves to precisely target and eliminate liver tumors while avoiding the complications of surgery or radiation. The technique, which the FDA authorized in 2023, has shown a 95% success rate for treating liver lesions. Despite the data and FDA authorization, Kirkland's insurer, Anthem Blue Cross Blue Shield, denied a prior authorization request for the procedure in May. In July, Anthem approved a subsequent request, and Kirkland had his first histotripsy later that month. But this approval shift did not indicate better times ahead for Kirkland. The opposite. Starting in early August, Anthem denied approval for Kirkland's two subsequent histotripsy procedures, calling the procedure 'not medically necessary,' and, in November, reversed its July approval because of a coding issue. Anthem's medical policy considers histotripsy an 'experimental or investigational treatment for liver cancer,' Janey Kiryluik, staff vice president for corporate communications at Anthem's parent company Elevance Health, told Medscape Medical News in a statement. After numerous appeals in the fall of 2024, the insurer upheld its decision not to cover Kirkland's histotripsy procedures. Without coverage, the three procedures cost about $150,000 out of pocket, according to Kirkland. Although the exact frequency remains hard to pin down, coverage denials have become increasingly common among major health insurers, like Anthem, and the rise appears to be fueled, in part, by insurers' use of artificial intelligence (AI) algorithms to review prior authorization requests and then deny claims in batches. In some cases, rates of denials may be 16 times higher when reviewed by AI tools than by humans, according to figures from a recent American Medical Association report. While most denials are ultimately overturned, that can take days, sometimes weeks or months, and delay life-saving cancer care. In a 2024 survey of radiation oncologists, for instance, 30% reported that the prior authorization process harmed their patients, and 7% said it led or contributed to a patient's death. 'Every time insurers create a delay or a hurdle, it potentially complicates care,' said Kirkland's Oncologist, Laura Tenner, MD, MPH, an associate professor in the Division of Oncology and Hematology at the University of Nebraska Medical Center, Omaha, Nebraska. 'There have been some significant delays in prior authorizations and coverage by insurance companies that have delayed care to the point where patients missed out on curative intensive therapy for cancers.' To limit the delays, patients like Kirkland may be left with an impossible choice: Find a way to pay for their care and potentially fall into deep debt or delay their care while fighting the insurance company. Kirkland couldn't wait. In October and November 2024, he underwent two more histotripsies. To cover the cost, Kirkland and his wife exhausted their children's college funds and borrowed money from friends and family. In January 2025, Kirkland received some encouraging news: The procedures, plus the chemotherapy, had killed off enough of his cancer for his medical team to approve him for a liver transplant. 'I was on cloud nine once I got the good news from being cleared for transplant,' Kirkland said. 'I thought 'This is the best news ever! I'm going to be there for my kids.'' Kirkland and his family Kirkland started the transplant testing process. His brother agreed to be his donor, and a transplant date was tentatively set for February 14. But those plans halted abruptly. The family received a letter from Anthem denying coverage for the transplant. In the letter, dated February 6, 2025, Anthem claimed that the requested transplant was 'medically unnecessary.' 'Medical studies do not show that this surgery will improve your short- or long-term health,' Anthem officials wrote in the letter, which Kirkland shared with Medscape Medical News . 'It was a gut punch,' Kirkland said. 'This can't be real.' Denial-Fighting AI Enters the Scene Desperate to get the care he needed, Kirkland and his family turned to social media. By this point, Kirkland's out-of-pocket costs totaled about $250,000. Within days of sharing his story, Kirkland's posts on Facebook and LinkedIn garnered more than 6000 shares. The LinkedIn post even caught the attention of billionaire Mark Cuban who offered to help pay for the transplant. But it was a new AI startup called Claimable that turned the tables for Kirkland's insurance fight. The company, which launched in October 2024, is one of a growing crop of AI-based companies using the technology to help patients and providers analyze health insurance claim denials, uncover issues, and ultimately appeal and overturn denials. Health policy analysts say the new wave of companies is part of a growing 'battle of the bots' as health insurers increasingly use AI to deny claims. 'It's not surprising that new AI companies have sprung up,' said Michelle M. Mello, JD, a health law scholar at Stanford Law School who researches the effects of law and regulation on healthcare delivery. 'On the provider side, there are more denials than people to process them, and one of the things AI tools can do is help figure out which denials are most likely to be overturned if appealed. Often, the reason something is denied is just that information is missing. So having AI systems in place that can figure out, can learn, and can put in that additional information, that seems really valuable.' Claimable does not specialize in cancer cases, but when the company caught wind of Kirkland's story through social media, Warris Bokhari, MD, a former National Health Service physician behind the company, wanted to help. 'We probably spent a couple of hours on the phone with Nathan and then spent the rest of the day working with his brother and his sister to piece together the story,' said Bokhari, who previously led healthcare strategy and innovation across corporate America, including Anthem. 'We went through every test, every imaging result. We went through all of the evidence. And over the course of the day, we basically put together an appeal that was then elevated to visibility at the insurance company.' Bokhari discovered that Anthem had Kirkland's diagnosis wrong on the liver transplant denial. And it wasn't the first time. Anthem had initially misidentified Kirkland's cancer as neuroendocrine cancer, not intrahepatic cholangiocarcinoma, in a previous histotripsy denial. Although the original denial letters and initial appeal letter referred to liver cancer, Kiryluik told Medscape Medical News that the ''neuroendocrine cancer' term was inadvertently inserted by a medical director reviewer from a drop-down screen in place of 'liver cancer' which appears immediately above on the drop-down screen.' But 'this error did not impact the decision,' Kiryluik wrote. The second time occurred in the transplant denial letter from February 6, which listed Kirkland's cancer as hilar primary sclerosing cholangiocarcinoma — also a form of bile duct cancer, but one that develops outside the liver. The crux of Kirkland's appeal, however, was that Anthem was using data from 2004 to support its denial, Bokhari said. This is not unusual. Bokhari has found that many insurance companies rely on poor or out-of-date evidence or inconsistent enforcement of policies to make claim decisions. To unearth such issues, Claimable's AI platform analyzes patients' medical cases alongside clinical evidence, policy details, and appeal precedents in similar cases. The company charges patients about $50 fee for the service. In Kirkland's case, Claimable pointed to studies starting in 2018 that showed outcomes for patients with cholangiocarcinoma drastically improved following neoadjuvant chemotherapy and a liver transplant. The 5-year survival rate was close to 60%, according to a recent study. 'That was significant,' he said. 'And ultimately, our involvement was really to show that this should be a clinical decision between the transplant surgeon and Nathan.' Bokhari said it's unclear if Anthem used AI in Kirkland's claim denials — he becomes suspicious when denials include errors and incorrect terms — but the denials could have also been based on 'incompetent review,' he added. Anthem denies using AI in its coverage decisions. 'AI is not used in denial decisions,' Kiryluik told Medscape Medical News . 'Denial decisions are made by an appropriate medical director through our peer clinician review process.' 'Battle of the Bots' Claimable sits alongside a small but growing number of companies using AI to help physicians and patients fight health coverage denials. In June 2024, Flight Health Insurance launched a platform to help patients appeal denials and, in April 2025, expanded its reach to providers with a platform called Fight Paperwork. In November 2024, Cofactor AI introduced an AI-powered platform called Cofactor Denial Suite that supports claim appeals for providers. In January 2025, payment software company Waystar announced the launch of Waystar AltitudeAI™ to help providers appeal denied medical claims. And in April 2025, Red Sky Health unveiled its new AI-solution, Daniel, which helps providers identify and correct claims errors. Holden Karau, a software development engineer who created Flight Health Insurance, has been thinking about insurance coverage issues since being hit by a car in 2019. While the insurer paid for her 'bones to be fixed,' Karau said nearly every other aspect of the process ended in a payment dispute. Only recently has the technology gotten to a point where it made sense to work on a platform to help fight denials, Karau said. Like Claimable, Karau's company keeps the process simple and the costs low for patients and providers. 'The hope is to keep the prices low because we think that there's just so many denials out there that aren't being appealed,' Karau said. A Hard-Won Transplant That Didn't Come to Pass Six days after the February 6 transplant denial, Kirkland learned that Anthem had reversed its decision based on 'new information.' According to Bokhari, Claimable is currently beating about 85% of health coverage denials. Kiryluik told Medscape Medical News via email that the initial coverage request was 'denied due to lack of medical necessity based on the provided information.' 'After Mr Kirkland contacted us on February 9, we initiated an appeal process, which included further discussions between our oncology medical director and his transplant surgeon,' Kiryluik said in a statement. 'It was during this review that new details were provided, including an updated diagnosis and data on the transplant center's success rates for patients with similar diagnosis,' Kiryluik explained. Claimable's letter, for instance, corrected Kirkland's cancer diagnosis and cited data from Kirkland's transplant team showing that all 10 patients with intrahepatic cholangiocarcinoma who had received a liver transplant at their institution had survived. 'With this new information, Anthem approved coverage for Mr Kirkland's liver transplant and informed him of the decision,' Kiryluik said. But time was not on Kirkland's side. After Anthem reversed its denial, Kirkland's medical team immediately rescheduled his transplant. Physicians knew it was urgent he received his transplant before his cancer metastasized . Kirkland was prepped and headed into surgery on February 14, which he called 'fitting' because the date happened to be National Organ Donor Day. Surgeons opened him up. Before the transplant, his team first wanted to biopsy a retroperitoneal lymph node. The biopsy came back positive for cancer, indicating the tumor had metastasized. Because the lymph node was outside the surgical resection field, Kirkland's cancer would not have been fully removed, even with a liver transplant, explained Tenner. The transplant procedure was cancelled. Kirkland and his family were crushed. A curative liver transplant is now off the table for Kirkland and the goal is to explore palliative therapies to extend his life and give him the best quality possible, Tenner said. His oncology team is also looking into clinical trials for him, she said. But there's a lingering question: Did Kirkland miss the slim window he may have had for curative intent therapy because Anthem's prior authorization process and coverage denials delayed his care? 'There is a chance that had things been approved quicker and a biopsy obtained, the cancer would not have spread at that time, but I can't give you a definitive 'yes' or 'no' on that,' Tenner said. Ultimately, Anthem also reversed its denials of Kirkland's histotripsy procedures after Claimable got involved. Kirkland also believes the social media attention surrounding his case contributed to Anthem's shift. But the insurer told Medscape Medical News that 'Anthem approved coverage of the histotripsy following an external review by an independent peer review organization. Consideration was given to several factors, including the member's unique clinical circumstances and documentation by the treating facility that the member had exhausted all evidence-based therapies, and other alternative medical services were not available outside of a clinical trial.' In late May, Kirkland finally received his first reimbursement check for $97,000 of the $250,000 he had paid. Even the reimbursement process was 'slow and messy,' he said. He is still waiting for the remaining amount, and his surgeon is still waiting to be paid by Anthem, he said. Despite his outcome, Kirkland said he's 'not done fighting.' He hopes his story will draw attention to unfair insurance denials and lead to changes in company policies. In February, he filed an ERISA appeal to Anthem, urging the insurer to make changes in its policies for patients who need liver transplants and FDA-backed histotripsy procedures. 'At this stage, it's more about making sure other people get the opportunity and the care they need to have a better outcome,' he said. 'It shouldn't be such a burden to get treatment.'
Forbes
15-07-2025
- Business
- Forbes
Elevance Health: Should You Buy ELV Stock Ahead Of Its Upcoming Earnings?
CHONGQING, CHINA - JULY 13: In this photo illustration, a smartphone displaying the logo of Elevance ... More Health, Inc. (NYSE: ELV), a major American health insurance provider and parent company of Anthem Blue Cross Blue Shield, is held in front of a screen showing the company's latest stock market chart on July 13, 2025 in Chongqing, China. (Photo illustration by) Elevance Health (NYSE:ELV) is set to report its earnings on Thursday, July 17, 2025. For traders focused on events, analyzing past stock performance surrounding earnings announcements can yield valuable insights and potentially improve trading strategies. In the last five years, ELV has shown positive one-day stock returns in 55% of cases following earnings announcements. The median positive return on those days was 2.7%, while the highest one-day positive return reached 7.7%. Additionally, see – Will The Rally In XRP Price Continue? Traders can tackle earnings announcements using two primary strategies: Analysts' consensus projections for Elevance Health's forthcoming report indicate earnings of $9.19 per share on revenue of $48.26 billion. This is a contrast to the same quarter last year when the firm reported earnings of $10.12 per share on revenue of $43.22 billion. From a fundamental perspective, Elevance Health currently possesses a market capitalization of $77 billion. Over the previous twelve months, the company has generated $183 billion in revenue alongside a net income of $5.9 billion. However, if you are looking for growth potential with less volatility than individual stocks, the Trefis High Quality portfolio offers an alternative—it has outperformed the S&P 500 and delivered returns surpassing 91% since its inception. Additionally, explore the growth potential in Google Stock To $350? See earnings reaction history of all stocks Elevance Health's Historical Odds Of Positive Post-Earnings Return Here are some insights on one-day (1D) post-earnings returns: Further information regarding observed 5-Day (5D) and 21-Day (21D) post-earnings returns, along with the relevant statistics, is contained in the table below. ELV 1D, 5D, and 21D Post Earnings Returns Correlation Between 1D, 5D, and 21D Historical Returns A relatively lower-risk strategy (although not beneficial if the correlation is weak) is to comprehend the correlation between short-term and medium-term returns following earnings, identify the pair with the highest correlation, and execute the relevant trade. For instance, if 1D and 5D exhibit the strongest correlation, a trader could take a "long" position for the subsequent 5 days if the 1D post-earnings return is positive. Presented here is some correlation data based on both 5-year and 3-year (more recent) histories. It should be noted that the correlation 1D_5D refers to the relationship between 1D post-earnings returns and the following 5D returns. ELV Correlation Between 1D, 5D and 21D Historical Returns Discover more about Trefis RV strategy, which has outperformed its all-cap stocks benchmark (a mix of the S&P 500, S&P mid-cap, and Russell 2000) to yield significant returns for investors. Moreover, if you desire growth with a smoother experience than an individual stock like Elevance Health, contemplate the High Quality portfolio, which has surpassed the S&P and achieved >91% returns since its inception.
Yahoo
09-04-2025
- Health
- Yahoo
Colorado couple's insurer denied claim for $94K air ambulance bill after husband had heart attack
When Bob and Marjean Taylor went to stay in a friend's cabin an hour from the nearest hospital back in 2022, neither expected that Bob would have his second heart attack within four months while they were vacationing. Unfortunately, that's exactly what happened. Marjean took him to the local hospital, but they were told he needed more care than the facility could provide. An air ambulance arrived, transporting him to a medical center where his cardiologist was waiting to repair a stent that had torn. The procedure saved his life, but sadly, Bob's troubles weren't over. I'm 49 years old and have nothing saved for retirement — what should I do? Don't panic. Here are 5 of the easiest ways you can catch up (and fast) Nervous about the stock market in 2025? Find out how you can access this $1B private real estate fund (with as little as $10) Here are 3 'must have' items that Americans (almost) always overpay for — and very quickly regret. How many are hurting you? Soon after they returned home, the Pueblo, Colorado couple received notice that their insurer, Anthem Blue Cross Blue Shield, was denying their claim for the air ambulance, saying the transport wasn't medically necessary and sticking the Taylors with a bill totaling around $94,000. 'It gave me a heart attack, almost,' Marjean told Denver7 Investigates of the unexpected bill. Unfortunately, air ambulances have become very expensive, and a growing number of insurers are denying claims for them, leaving Americans who've suffered medical crises holding the bag. Here's what you need to know. Air ambulances are helicopters or planes designed to provide timely transport of patients to medical facilities. They're often used in rural areas where medical care is scarce. With an aging population, more people relocating to remote areas during COVID-19, and the increased prevalence of infectious diseases, the market for air ambulances is growing. In fact, according to Technavio, a market research group, the air ambulance market saw 9.63% year-over-year growth from 2022 to 2023 and is expected to increase by $6.77 billion between 2024 and 2026. Sadly, prices for air ambulances have skyrocketed, as a growing number of private equity firms have moved into the market. One would think that insurance companies would cover the costs of air ambulance services in most cases, since they're almost always called in emergencies. Unfortunately, data shows a growing number of insurers are denying claims. Part of the problem is that when an air ambulance is called, patients aren't checking if the company is in-network or not. This may not be a high priority when you're being airlifted to a hospital during a heart attack or in the wake of an accident. It shouldn't matter if the ambulance service is in-network, as starting in 2022, policyholders were supposed to be protected from unexpected bills under the No Surprises Act. This act prohibited surprise bills for: Most emergency services, regardless of whether they're in network or out-of-network Out-of-network services provided when a patient visits an in-network facility (such as anesthesia administered by an out-of-network anesthesiologist at an in-network hospital) Read more: Trump warns his tariffs will spark a 'disturbance' in America — use this 1 dead-simple move to help shockproof your retirement plans ASAP However, insurers can still pass on out-of-network costs to claimants if the service isn't considered medically necessary. Perhaps unsurprisingly, insurers now claim that many ambulance trips aren't needed. In fact, the National Association of EMS Physicians warned policymakers in a February 2024 letter that they have seen a 'spike in denials of claims on the basis of 'lack of medical necessity.'' Being transported to a hospital during a heart attack seems pretty necessary — and yet the Taylors were still told they had to pay. They had to go through multiple appeals over two years and ultimately get the press involved before the insurer finally resolved the issue, blaming unclear communication for the problem. Not everyone will be lucky enough to get the press involved, though, and the couple faced a lot of stress in the meantime. 'I just felt like we were stuck in the middle of all these companies and nobody cared,' said Marjean. 'After I got off the phone, I said, 'I cannot believe this is done,' and I started crying. But I wasn't giving up. I was not going to give up. I was not paying for it.' Air ambulance costs are a growing issue, but there are other ways you could find yourself stuck with a hefty bill for health care services. Here are some steps you can take to protect yourself: Get pre-approval for medical services from your insurer in non-emergency situations Know your rights under the No Surprises Act Shop carefully for the right insurance policy that offers comprehensive coverage from a provider with a good reputation. Visit in-network providers whenever you have the option Request itemized bills to understand what you're being charged for Negotiate with providers and the billing department if you think you're being overcharged Appeal denied claims, and be prepared to provide documentation Hire a medical bill advocate to help you fight unfair bills These steps can help you avoid the financial devastation that comes with big medical bills your insurer should pay for, but does everything possible to avoid. Want an extra $1,300,000 when you retire? Dave Ramsey says this 7-step plan 'works every single time' to kill debt, get rich in America — and that 'anyone' can do it Rich, young Americans are ditching the stormy stock market — here are the alternative assets they're banking on instead Cost-of-living in America is still out of control — and prices could keep climbing. Use these 3 'real assets' to protect your wealth today, no matter what Trump does This article provides information only and should not be construed as advice. It is provided without warranty of any kind.
