WALLINGFORD, Conn. — Anthem Insurance has changed its story when it comes to making sure kids with special needs across Connecticut get the therapies deemed medically necessary by their health providers.
State and federal lawmakers are paying close attention and are putting the insurance giant on notice that legislative action may be coming.
FOX61’s exclusive investigation on Oct. 2 uncovered that healthcare insurance giant Anthem planned to slash the amount of money it reimbursed providers for performing special needs therapies. The decision would have negatively impacted healthcare providers, kids with special needs and their families.
Anthem Insurance originally responded to that investigation by saying, “After further evaluation… we will continue to reimburse… at a fee-for-service rate instead of the proposed Oct. 1 rate change…”
But after that indication that rates would stay the same, FOX61 began to get reports that Anthem wasn’t being straightforward.
“What are they doing?” asked Republican state Sen. Jeffrey Gordon. “We can’t have double speak.”
FOX61 was able to obtain specific rate tables that show Anthem therapy reimbursements before and after Oct 1. Some reimbursement codes increased while others decreased.
Anthem said, “The aggregate impact… is the same.”
“You can trust, but you have to verify,” said Gordon.
FOX61 asked Anthem to back up their assertion by revealing the data they used. They refused and said, “Our contractual rates are proprietary and confidential.”
“Why is Anthem making changes in the first place that can directly affect the care of thousands of people in Connecticut, especially children,” questioned Gordon.
Gordon knows a little something about healthcare. He’s a cancer doctor and a former chair of the state medical society.
Gordon has been following FOX61’s investigation and expressed concern. He and state Sen. Lisa Seminara wrote a letter to Anthem.
“I’m concerned it’s going to have a negative impact on patient care,” said Gordon. “Every week, I’m going to be after Anthem to make certain we get an answer and that we get an answer that makes sense.”
RELATED: State senators applaud FOX61 reporting on reversed Anthem rate cut
But for occupational therapists like Alescia Ford, none of it makes sense.
“I got into the business to help kids,” said Ford.
Nearly 17% of kids in Connecticut have a disability, so the need for therapy is increasing.
“But we’re being reimbursed less for our time,” said Ford. “We are seeing more restrictions on access to care, more hurdles to jump through and more red tape.”
FOX61 toured Alescia’s office, Adapt & Learn Pediatric Therapy Services in Farmington, where her play-based sensory therapy helps kids regulate their emotions and learn new skills.
“The kids love our climbing wall,” added Ford.
But now, “There’s a rate cap,” said Ford.
FOX61 learned that while Anthem did go back to reimbursing speech therapists for each service they perform, they’ve transitioned to a daily rate cap for kids who need occupational and physical therapy.
“A rate cap is a daily maximum. No matter how much service times or therapy your child needs, the insurance company will only reimburse that one rate,” explained Ford.
FOX61 obtained a message from a provider sent to families that said, “...we had to carefully consider… shifting to an 'out of network' provider OR changing the duration of our therapy sessions...”
A rate cap forces families who used to be provided with multiple therapy services in one day to split their appointments into multiple days. That means more travel, more gas money and less convenience. In addition, because some insurance plans also have visit caps, splitting up appointments means families reach those caps faster. Once a cap is reached, kids don’t get any therapy.
“The family is going to be bearing the burden of these changes,” said Ford, adding that kids deserve better. “Absolutely. They deserve everything we can give them because, ultimately, in the long run it will benefit everyone.”
In search of data transparency and accountability, FOX61 went to Anthem’s headquarters in Wallingford to speak with its president about these policy and rate changes.
The head of security said President Lou Gianquinto was in meetings and that he didn’t know how to reach him or obtain his contact information.
As a company, Anthem brought in over $171 billion in revenue in 2023. Their CEO, Gail Boudreaux, was paid over $20 million in 2022.
Many therapy providers were too nervous to speak to FOX61 about this report. They said they are concerned about retribution and antitrust laws that effectively gag providers from advocating.
In a statement to FOX61 Anthem did fire a warning shot to providers who speak out saying, “Any provider disclosure would be considered breach...”
RELATED: Rate increases sought by insurance companies should be rejected: Connecticut Attorney General
Alescia Ford said her decision to speak out is, “An issue of morality... Providers sign contracts with big insurance companies and one of the stipulations is that we do not advocate. We do not speak up, we don’t share details. We uphold our end of the bargain. But when we have a contract that is unilaterally changed with absolutely no data to support that change and no opportunity for negotiation, I don’t feel heard.”
Gordon says that’s a problem.
“I don’t think there should be these gag orders or concerns about retribution or the insurance company dropping you because you speak out because when doctors and healthcare professionals are speaking out they are speaking out for their patients.” He added, “If there’s something that should be done legislatively, I’m not afraid to do it.”
FOX61 also discovered that not all therapy providers are given a level playing field. Providers who are attached to a big hospital conglomerate like Hartford Healthcare or Yale are often able to engage in direct rate negotiations with Anthem and are often reimbursed double what small independent providers are given for performing the same therapies.
The real world impact of this means families of children who receive therapy from small specialized providers have less leverage to fight back against a large powerful insurance company.
Anthem is Connecticut’s largest healthcare insurance provider with over 1.5 million members.
The Office of the State Healthcare Advocate told us the company lacks oversight.
“Their rates aren’t directly regulated by any government,” said Sean King, a staff attorney at the Connecticut Office of the Healthcare Advocate.
King said the country’s healthcare delivery system is largely broken. “If there was a consensus on how we can fix it, it would have been fixed by now.”
FOX61 had offered multiple times to conduct an interview with Anthem. The company has chosen to communicate only through statements from their director of public relations.
Matt Caron is a reporter at FOX61 News. He can be reached at mcaron@fox61.com. Follow him on Facebook, X and Instagram.
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