One in six could be denied coverage under Anthem policy
A policy of denying emergency coverage by Anthem Blue Cross Blue Shield could leave nearly one in six patients vulnerable if it is adopted nationwide.
Anthem has come under fire over its policy, which denies coverage retroactively, after patients have already received services in emergency departments based on diagnoses. The practice is active in six states: Indiana, Kentucky, Missouri, New Hampshire, Ohio and Georgia. Anthem is already facing at least one lawsuit from the American College of Emergency Physicians and the Medical Association of Georgia.
Should the policy spread beyond these states, the consequences for patients could be severe, according to a study by Harvard and Yale researchers published in JAMA.
The study comes at a time when surprise billing––when patients receive massive medical care bills in the mail after they’ve received care––has garnered significant headline attention in the media. Similarly, Envision has recently come under fire for its own billing practices that leave patients blindsided with sky-high bills.
Anthem’s list of non-emergent diagnoses would require patients to self-diagnose before seeking care in emergency departments and could disqualify 15.7 percent of commercially insured adult ED visits for possible coverage denial.
“It is unreasonable and dangerous to force patients to self-diagnose before going to the emergency room,” Vidor Friedman, MD, president of ACEP, said in a statement. “Insurers cannot expect a patient to know in advance whether a headache is a migraine or an aneurysm, or if abdominal pain is indigestion or something far worse. In addition to sticking patients with large medical bills, this policy could deter people from going to the emergency department in a situation where they need immediate medical attention.”
ED visits that don’t qualify for coverage under Anthem’s policy share the same symptoms of 87.9 percent of ED visits, where 65.1 percent received emergency-level services, such as imaging or blood tests. This finding reveals that a retrospective diagnosis-based policy “is not associated with identification of unnecessary ED visits,” and puts many patients at risk of coverage denial.
“This policy could place many patients who reasonably seek emergency care at risk of coverage denial,” lead author Shih-Chuan (Andrew) Chou, MD, MPH, attending physician in the Department of Emergency Medicine at Brigham and Women’s Hospital, et al. wrote.
"If a consumer chooses to receive care for non-emergency conditions at the ED when a more appropriate setting is available, Anthem will request more information (including additional medical records) from the hospital and a statement from the consumer as to why they went to the ED," Anthem told HealthExec in a statement. "An Anthem medical director will review the additional information using the prudent layperson standard, and the claim might be denied as not a covered service. In the event a consumer’s claim is denied, they have the right to appeal.
Anthem has made, and will continue to make, enhancements to ED Review to help consumers receive the right care at the right place and time."
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."