Q: I desperately need your help with Anthem Blue Cross. Almost two years ago, I underwent emergency spinal surgery after an accident – it was medically urgent to prevent permanent damage.
My health insurance company, Anthem Blue Cross, paid the hospital, ICU stay and anesthesiologist without issue. But it has denied the $18,926 surgeon’s fee, claiming it lacked authorization from its third-party partner, Carelon.
Here’s the maddening part: Carelon repeatedly states that “no authorization is needed” for this emergency procedure. Anthem and Carelon refuse to talk directly, leaving me and my surgeon’s office stuck in the middle, making over 80 phone calls to try and resolve this issue.
Every time we follow Anthem’s instructions, it rejects the claim weeks later for a new reason: “missing records” (they misfiled them), “wrong appeal form,” or “untimely submission” — even when we acted on its directives. We filed multiple appeals, including one Anthem specifically requested during a three-way call. They denied it anyway.
The cruelest twist? Anthem imposes a strict two-year deadline to resolve claims. Our window slams shut in a few weeks. I’m exhausted and terrified of being stuck with this bill. What can I do when the insurer and its own partner can’t agree on their rules?
— Hien Shields, Sunnyvale, Calif.
A: After having emergency surgery, the last thing you should face is a 21-month odyssey through a bureaucratic maze built on contradictory demands and missing paperwork. Anthem’s obligation wasn’t just to process your claim – it was to provide clear, consistent guidance and ensure that its partners, such as Carelon, are aligned on policies for urgent care. Instead, they left you mediating a dispute between their own departments. That’s inexcusable.
Under state and federal law, Anthem was obligated to cover emergency services deemed medically necessary without requiring prior authorization. When Carelon stated no authorization was needed, Anthem should have resolved the internal disconnect immediately.
Losing records, giving conflicting instructions and ignoring appeals until deadlines nearly expired are a problematic business practice. California law requires timely responses (typically 30 days for claims, 60 for appeals).
While you did nearly everything right – documenting calls meticulously, enlisting your provider’s help and persisting through appeals – starting your written paper trail earlier could have accelerated things. After the first denial, sending a formal appeal creates a better record. Always get names and reference numbers from every call. If a rep promises action, ask for an email confirmation.
When companies stonewall, escalate to executives. I publish contacts for exactly this reason: Here are the names, numbers and emails for Anthem Blue Cross.
I contacted Anthem several times on your behalf. In a stunning but telling twist, your surgeon’s office zeroed out the $18,926 charge shortly after my inquiry. While I’m relieved for you, this resolution is bittersweet. It underscores a grim reality: Providers sometimes abandon valid claims because fighting insurers is more costly than the debt itself.
Christopher Elliott is the founder of Elliott Advocacy, a nonprofit organization that helps consumers solve their problems. Email him at chris@elliott.org or get help by contacting him at the nonprofit’s site.