RICHMOND, Va. (WWBT) – The State Corporation Commission’s recent action on two large health insurers in Virginia is bringing the complexities and sometimes inaccuracies of medical billing to light.
The SCC ordered Cigna Healthcare and Anthem to refund a combined 900+ customers after a Bureau of Insurance investigation found the two insurers unlawfully billed for some services.
Cigna was forced to repay $404,000 to clients it told would receive less coverage on claims based on the patient’s eligibility for Medicare, which is illegal in the state.
Anthem paid out nearly $217,000 because it charged customers a copay for a brand-name contraceptive deemed necessary by their doctor between 2021 and 2024, which involved 1,287 claims.
Virginia law says health insurers must cover preventive services, including contraception, and they cannot impose any cost-sharing for those services.
Anthem said the over-billing error was a result of a system coding problem.
Both Cigna and Anthem had to pay the state fines as well.
“40% of all medical bills have some form of error on it. Doesn’t mean that every time it’s a financial impact, but a lot of times it is,” HealthLock CEO & Founder Scott Speranza said.
Speranza is a medical billing expert. His company, HealthLock, tracks health insurance claims for its customers and fights any billing battles on their behalf.
“There’s the overcharges, there’s the fraud, and then there’s that specific category of claim denials. There’s probably over a trillion dollars in total lost to the consumer via those three items,” Speranza said.
He says several technical issues can lead to inaccurate billing.
“It’s a very complicated transaction between the provider and the carrier,” Speranza said. “There’s 100,000 line items. It’s actually more complicated, probably than the IRS tax system, and so if anything is wrong in that process, you get a denial or a partial denial.”
Speranza says it’s up to the individual to ask questions, understand what services are being provided, what you are being billed for, and whether it is “in-network” or “out of network.”
That way, if you receive a questionable bill, you can call your provider and follow up with your insurer to straighten it out.
But be prepared to spend a lot of time on the phone.
“And by the way, appeal,” Speranza said. “So remember, there’s always denied claims, but only 1% of people appeal that. It’s complicated, but you can do it.”
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