Emergency? Anthem Asking Patients, Not Doctors to Decide

By John R. Corker, MD

Sincere and well-informed reassurance is a big part of any savvy Emergency Physician’s daily routine.  Patients present with symptoms that scare them; enough to go to an Emergency Department, where long waits, a higher co-pay, and potentially big bills surprise no one. Emergency physicians are charged with synthesizing these complaints, along with a litany of other information, into a coherent plan of examination and testing to establish and ensure their patients’ safety.

More often than not, these ED encounters result in mostly reassuring findings. And the physician’s biggest challenge can then be translating that reassurance – in a way that only a highly trained and knowledgeable professional can – to a worried and vulnerable patient.

In 2017, in an attempt to reduce their costs related to ED visits, Anthem Blue Cross Blue Shield (ABCBS) informed their enrollees in six states (Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio) of a new policy denying insurance coverage for Emergency Department visits that are retrospectively determined not to have represented an emergency. Anthem states that they worked with four unnamed emergency physicians in their employment to help them identify medical codes (diagnoses) that could be considered retrospectively to be “non-emergent.” And they decided to deny insurance coverage for any visit coded with one of these diagnoses.

When the policy was first rolled out, patients’ medical records were not reviewed until or unless the patient or physician appealed Anthem’s denial of coverage. Instead, the insurer was relying strictly on the claims submission it received, which contained at most a few ICD-10 diagnosis codes. The appeals process is a notoriously complicated and expensive endeavor for patients and physicians, which in and of itself serves as a powerful deterrent.

In an attempt to explain their reasoning behind this new policy to retroactively deny coverage, Anthem spokesperson Tony Felts wrote in an email: “The ultimate goal of this is to encourage more efficient utilization of health care resources, relieve pressure on ERs that are already stretched thin and strengthen the relationship between our members and their primary care doctors, who are in the best position to influence the health of their patients.”

However, emergency physicians and patients alike are concerned that this new policy is asking patients to perform the very same highly skilled initial evaluation and triage process traditionally entrusted to their physicians. “The problem is that many diagnoses, their symptoms overlap, and without a thorough evaluation by a physician, you can’t tell until that evaluation is complete,” wrote Dr. Chris Burke, an emergency physician and board member of the ACEP Indiana Chapter. “It’s wrong to insist that patients should self-diagnose. Most are not able to do that. I think most who come to the emergency department believe that they have a problem.”

Both state and federal policy-makers have already begun to respond to physician and patient concerns.  United States Senator Claire McCaskill of Missouri, in a letter sent to Anthem this past December, questioned this policy’s legality under the federal “prudent layperson standard,” which is codified in the Affordable Care Act, as well as in some form in 47 states. This law requires that insurance coverage be based on a patient’s symptoms, not their final diagnosis. It also prohibits insurance companies from requiring patients to seek prior authorization before seeking emergency care.  

Furthermore, Senator McCaskill requested all documents, presentations, and communications related to the genesis and execution of this policy, as well as any patient complaints related to it.  This information was requested by the end of January 2018 but, as of Feb. 14, Anthem had not provided any documents to Senator McCaskill.

In addition, bills introduced in Missouri and in Georgia contain language aimed at stopping Anthem’s policy. As well, Ohio state representatives Alicia Reece and Thomas West are currently drafting their own legislation to include provisions that would deny Anthem, or any health insurer who refused to pay for services at the ER, access to tax credits and government contracts with the State, Counties, and Cities of Ohio. They want to send a “strong message” to Anthem that Ohio “will not stand for these types of business practices,” and have sent a letter to Ohio governor John Kasich asking for his support.  

Notably, physician and patient advocacy groups like ACEP, its chapters, and the American Medical Association (AMA), among others, have long provided support and resources for these efforts and many like them in other states. Since word first broke in 2016 that Anthem was considering this policy, representatives from these organizations have been meeting with Anthem, state departments of insurance and state Attorneys General to express their concerns about the potentially dangerous consequences that this policy could have for patients in need.  And, due in part to these efforts, Anthem has begun to make changes. In mid-February, Anthem added the following list of circumstances under which patients’ ED visits will always be covered:

• The consumer was directed to the emergency room by a provider (including an ambulance provider)
• Services were provided to a consumer under the age 15
• The consumer’s home address is more than 15 miles from an urgent care center
• The visit occurs between 8:00 PM Saturday and 8:00 AM Monday or on a major holiday (New Year’s Day, Martin Luther King Day, President’s Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas.)
• The consumer is traveling out of state
• The consumer received any kind of surgery
• The consumer received IV fluids or IV medications
• The consumer received an MRI or CT scan
• The visit was billed as urgent care
• The ER visit is associated with an outpatient or inpatient admission

Additionally, Anthem has put out a statement detailing the following additional modification to its policy:

“Anthem will (now) request medical records from the hospital as part of the initial review process. For ER claims previously denied under the program, if a health care provider fails to comply with Anthem’s request for medical records for the re-review, Anthem will consider written statements from ‘consumers’ indicating their reasoning for the ER visit. An Anthem medical director will review the claim information using the “prudent layperson” standard. If a consumer feels he or she has an emergency, he/she should always call 911 or go to the ER.”

Of note, Senator McCaskill’s office has published a press release making it clear that these policy modifications are “not nearly enough,” and that her office still awaits the requested documentation from Anthem necessary to complete their investigation.   

Efforts are ongoing at many levels to convince Anthem to rescind this policy all together—after all, even with the expanded “exceptions”, this policy is still forcing patients to decide even before they leave the house whether or not their symptoms are caused by a true emergency.  But for now, thanks to our leadership in organized medicine, progress is being made.  For more information on this topic, how it may impact you and your neighbors, and how you can help, please contact ACEP (publicaffairs@acep.org) and your elected officials (https://www.usa.gov/elected-officials).