Anthem issues policy threatening nonpayment for ’nonemergency’ ED visits

Anthem BlueCross BlueShield, May 11, 2017

Save the ER for emergencies — Or you’ll be responsible for the cost

Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations.

But starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).


Physicians protest harmful Anthem emergency care coverage policy

By Andis Robeznieks
AMA Wire, August 7, 2017

A new policy by Anthem Blue Cross Blue Shield holds patients responsible for bills stemming from care delivered in emergency departments that is later deemed nonemergent.

The AMA has asked Anthem to immediately rescind the policy in states where it has been put into effect and halt implementation in all other states.

The AMA, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) also suggest that the new policy may violate the “prudent layperson standard” which has been codified into state and federal laws—including the Affordable Care Act (ACA). The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. Anthem’s retrospective review appears to be inconsistent with such a standard.


AMA Letter:

From: James L. Madera, MD, EVP and CEO, AMA
To: Joseph R. Swedish, Chairman, President and CEO, Anthem, Inc.

On behalf of the American Medical Association (AMA) and its physician and student members, I write to state our concerns with Anthem’s policy in several states to deny coverage of many emergency services when the diagnosis is retrospectively determined not to have required emergency care. We ask that Anthem rescind this policy in states where it has taken effect, and halt implementation in all other states.

Physicians know that patients and caregivers should never second guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion. But with this policy, Anthem is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring. Moreover, Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.



By Don McCanne, M.D.

What a bizarre policy this is. Anthem assigns to the patient the responsibility for deciding if a medical situation is an emergency. Anthem then assumes for itself the responsibility of deciding only after the care has been given whether or not it was an emergency after all, even though the perspective of that judgment can be quite different after a problem is evaluated and managed. If Anthem unilaterally decides, only in retrospect, that the patient’s judgment that this was an emergency was in error, Anthem may refuse to fulfill its obligation to pay for the emergency department services.

Think of various reasons that a decision could be made retrospectively that the visit was not an emergency. Consider those patients who are commonly blamed for wasting health care dollars by abusing the emergency department. Now back up and consider the reasons that the patients thought, before the visits, that they should go to the emergency department. Your ankle was only sprained and not fractured so it could have waited until your physician or nurse practitioner was available on Monday. You are from out of town and you found that your insulin wasn’t packed in your luggage and so your blood sugar is suddenly out of control. You feel very ill and there is an epidemic of a potentially lethal virus but it turns out that you just had a nonlethal respiratory virus, written off as a common cold, even though you really felt sick. You have a seizure disorder and are whisked away to the emergency department while still in a postictal state - the third time this happened. Although it is likely that Anthem would agree to pay for these visits, the threat of nonpayment might keep these people away in situations that might have turned out to be more serious.

Yet you hear all the time about how people are abusing the emergency department. Okay, so you hear about someone who wants a sports physical exam form filled out, but that person doesn’t make it past the triage desk. In my experiences with emergency departments, direct and indirect, I’ve decided that abuses severe enough to penalize a patient financially are so rare that they are basically a fiction that reform opponents keep propagating. Low acuity and low severity might be considered an issue, but that is still relative and not absolute, and the patient should not be penalized for having to make an uninformed decision. People do not go to emergency departments just for social visits.

Based on a “prudent layperson standard” then anyone that clears the triage desk should be assumed to be there legitimately. Under their nonpayment for non-emergency policy, either Anthem would be refusing to pay for legitimate services, or Anthem is making a major PR faux pas by issuing an unnecessary directive that will only make people angry. Either way, this is a terrible policy to establish. But what else do we expect from the private, for-profit insurance industry that places its own net profits over the health care of the patients?

I've decided after the fact that getting rid of the private insurers is a true emergency. Let's do it.

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