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Anthem Blue Cross Sanction Review

As my medical board investigations are rounding 3rd base, I will be starting independent investigations by CMS and private insurance groups.

I received a letter from Anthem Blue Cross that they recently flagged my medical license because I was investigated by the California Medical Board (CMB) and received a public reprimand on my record.

Of note, I have already undergone the individual medical group investigations and all of them terminated me because of the details of the investigation with the Oregon Medical Board.

This next part is dealing with the insurers and CMS.

Anthem Bluecross Sanction Review

If you are a physician under whom there is Medicare or Medicaid billing, you will need to be in good standing and any of your medical board investigation or malpractice cases have to reported to the 3rd party administrators.

Anthem Blue Cross handles the Medi-Cal cases in California. They have a lengthy provider manual which you can review (pdf). They refer to this investigative process as a Sanction Review under their Sanction Monitoring Program.

They do both random audits and have certain cases reported to them by state medical boards and employers. In my case, the CMB reported my public reprimand to Anthem.

Anthem has to take my case before their Credentialing Committee to determine if they will allow me to continue to participate with them. If not, I will receive a termination letter which usually cannot be appealed.

Credentialing Committee Request

Ever since my license suspension I haven’t been able to pass any credentialing committee scrutiny for the purposes of getting hired. However, insurance groups have different standards for credentialing.

The letter I received asked me to submit all evidence and detailed letters to them as to what took place and what actions have been taken against me.

This information can be mailed to them, faxed or emailed to them. You would obviously want to use an attorney if you want to maximize your chances of passing credentialing.

Reportable

This Anthem Blue Cross investigation is something that I have to report to all my state medical boards. And their final decision is reportable as well.

Don’t overlook this step. The medical boards are looking for you to slip up in order to slap you with another public reprimand letter or suspend or terminate your medical license for not complying with your state medical board rules.

Reporting Progress of Case

I use Online Certified Mail to communicate with the medical boards. As soon as I get a letter from any entity, I download it as a PDF and create my own PDF with my own statement. I then send those 2 documents to all 3 state medical boards.

With Online Certified Mail I get a sent/delivery confirmation through the USPS and the addresses are all saved so I don’t have to enter all this shit in multiple times. It’s pricey, $8 per letter send and it adds up fast.

Consequences

The consequences should be obvious. If a large CMS administrator like Anthem drops you, you will not be able to get hired by any medical group which bills CMS.

Furthermore, if you decide to start your own medical practice in the future and want to be able to bill such insurance groups, you’ll be excluded if you fail credentialing.

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