Anthem has been criticized and even sued over policies in several states where it won’t pay for emergency room visits it later determines to be unnecessary. The insurer has now softened those restrictions, but American College of Emergency Physicians (ACEP) said the changes don’t go far enough.
Anthem’s policy aims to steer patients away from visiting the ER when a less costly site of care would be more appropriate. Opponents of the policy, however, claim few ER visits are truly avoidable and Anthem could scare patients away from seeking necessary care. Making these decisions more complicated for patients is the fact Anthem’s determination is based on the final diagnosis, not the symptoms which prompted someone to seek care.
In a Feb. 14 blog post, Anthem said its modifying the policy in Georgia and Missouri by expanding its list of conditions which will always be approved for ER visits. It will apply this change retroactively, meaning denied claims as far back as July 2017 will be re-evaluated.
“It is important that we continue to address this trend because it is impacting the cost of healthcare for consumers, employers and the healthcare system as a whole,” the insurer said in the blog post. “At Anthem, we believe that getting care in the most appropriate setting is an important part of making healthcare simpler, more affordable and more accessible.”
ACEP didn’t give Anthem much credit for including the additional exceptions, covering patients who receive surgery, IV fluids or medications, MRI or CT scans, arguing those “should have always been exceptions.”
"Patients should not be forced to diagnose themselves out of fear their insurer won't pay. Most patients can't be expected to determine, for example, the difference between abdominal pain that is life-threatening and abdominal pain that isn't,” said ACEP president Paul Kivela, MD, MBA. “It's impossible for a patient to know before going to the emergency room whether they'll receive there the IV fluids, MRI, or surgery needed to ensure their visit will be covered. The decision to 'ride it out' instead of seeking emergency care could lead to life-long disability or even death.”
Sen. Claire McCaskill, D-Missouri, was similarly unimpressed, saying the change “isn’t going to cut it.”
“Anthem needs to take more meaningful action to change that reality and fully respond to my request for information underlying the rationale for this problematic policy,” she said in a statement.
A group of hospitals recently sued Anthem over its ER policy and a separate effort to push outpatient imaging to freestanding facilities, arguing the insurer is only motivated by a desire to reduce costs “regardless of the policies’ harmful consequences on access to medically necessary services, clinical integration, patient safety and quality of care.”