Anthem Changes to ED Payment Policy Leave Some Unsatisfied

Anthem said that it was adjusting its policy on paying for emergency department (ED) visits, but some advocates and healthcare associations said Friday the changes by the insurer don’t go far enough.

In addition, lawmakers in the Missouri House and Senate will consider legislation that would require a board-certified emergency physician to review the patient’s medical history regarding the ED visit before sending on a bill, according to the St. Louis Post Dispatch.

Anthem, based in Indianapolis, provides health coverage to more than 40 million people in several states. It said it was making the changes to cut down on unnecessary ED use. Anthem said this week that it has added a few more categories to when it will “always pay” for an ED visit.

In addition, Anthem said part of its initial review process will include requesting medical records from the hospital. Before January 1, 2018, the insurer did not use medical records—it used the claim information sent by the hospital.

“Adding the request for medical records to the initial review process will help provide a more comprehensive view of the reason the consumer decided to go to the ER [emergency room],” an Anthem spokeswoman said in an email.

Anthem said that previously denied claims that would have been approved using this new guidance will be overturned.

The healthcare industry has been grappling with rising costs, which are expected to rise 5.5% annually by 2026. One way is to curb non-urgent use of the ED and encourage more value-based, high-value care and avoid unnecessary tests and procedures.

That becomes a balancing act that is falling on patients, said some.

“While we appreciate that Anthem is reflecting on this policy and making adjustments, these changes do not go far enough. We remain deeply concerned that the message to patients is that they could be penalized if they seek care during what they believe to be an emergency,” said Molly Smith, vice president of coverage at the American Hospital Association, in a statement emailed to The American Journal of Managed Care^® (AJMC^®). “Too much is at stake, and we continue to urge Anthem to work with providers on ways to educate patients about the appropriate use of the emergency department instead of relying on blunt financial penalties.”

“The bottom line is, insurers need to use the prudent layperson standard,” said Betsy Imholz, special projects director of Consumers Union, the advocacy division of Consumer Reports.

Imholz also commented about Anthem now reviewing medical records as part of their review process. "Medical records are crucial, including in deriving presenting symptoms, so Anthem reviewing them seems very important—and basic. It's pretty shocking that they were not reviewing the medical records previously before when denying coverage," she wrote in an email.

"Research has shown that discharge diagnosis codes, such as those Anthem apparently has been using, are notoriously unreliable indicators of whether the need was truly an emergency,” she wrote.

Anthem said in a statement that "emergency rooms are an expensive place to receive routine care. The costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for patients, employers, and the healthcare system as a whole."

The total list of categories for which the insurer said it will always cover the cost of emergency care are:

• A patient was directed to the ED by a provider (including an ambulance provider)
• Services were provided to a patient under the age 15
• The patient’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
• The patient is traveling out of state
• The patient received any kind of surgery
• The patient received IV fluids or IV medications
• The patient received an MRI or CT scan
• The visit was billed as urgent care
• The ED visit is associated with an outpatient or inpatient admission

Imholz said she had other questions about the policy, such as whether a message on a provider's answering machine or voice mail that directs callers to go to the ED would protect someone against a bill. "We enacted the Affordable Care Act to ensure people were not unfairly denied coverage," she said, and said she feared that the policy feels like a backdoor way to do that service-by-service.

Anthem sent additional information to AJMC^® later on Friday, saying, "Most ER claims go through our system and are processed normally. A minority of ER claims are reviewed to determine whether, under the prudent layperson standard, the patient experienced an emergency condition. These claims are first filtered through the “always pay” exception list, and if they don’t meet any of those exceptions, an Anthem medical director will review the claim information using the prudent layperson standard, and the claim may be denied."^*

The American College of Emergency Physicians is also opposed to the policy.

^{*Reflects update after the story published.}