Recent controversial payment policies by Anthem, which deny payment for emergency department visits deemed non-emergent, were developed because of what the payer deemed as an overuse of unnecessary ED services.
“The emergency room is one of the most expensive possible places to be seen for medical care. Most ERs are designed to treat life or death emergencies like car accidents, gunshot wounds and heart attacks,” the payer explained in their policy announcement to members. “But nearly 50 percent of patients in the U.S. have sought care in the ER for non-urgent reasons.”
That assumption is being challenged, however, by reports from the Centers for Disease Control and Prevention (CDC) released earlier this year which show that only 5.5 percent of all ED visits are considered non-urgent. Of the 136 million ED visits evaluated, various injuries accounted for about 28 percent of visits, while illness, including chest and abdominal pain, accounted for about 65 percent of visits. Mental health related conditions or other reasons made up the remaining 7 percent or so.
“Patients are living longer, managing more complex and chronic conditions and for many reasons may not always receive regular primary care,” said Dr. Paul Kivela, MD, MBA, FACEP, president of the American College of Emergency Physicians (ACEP), in a recent statement. “This means the emergency department is now more than ever the ‘front door’ to the hospital – our care and reimbursement models must continue to evolve to reflect this reality.”
The stark difference between Anthem’s estimate of 50 percent non-urgent visits and the CDC’s 5 percent may be attributed to the difference between presenting and final diagnoses. Anthem’s policy denies claims based on the final diagnosis, while the CDC analyzed presenting complaints, or triage status. It’s an important distinction to note since the prudent layperson standard, codified in federal law, requires insurance companies to cover services based on whether or not a prudent layperson felt their presenting symptoms would result in “serious jeopardy to their health, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.”
According to ACEP, denying coverage for emergency visits not deemed to be emergencies, especially based on final diagnosis, puts patients in the “risky position of self-diagnosing, potentially delaying or avoiding necessary care.”
“Your insurance company is legally required to cover your emergency visit based on your symptoms, not the final diagnosis,” said Dr. Kivela. “Insurance that abandons you in an emergency is no insurance at all. With nearly 90 percent of urgent and nonurgent symptoms overlapping, insurers should not leave patients to figure out themselves if their symptoms are truly life-threatening.”
For more information, review the CDC National Hospital Ambulatory Medical Care (NHAMC) survey, which is based on 2015 data (the most recent available) pulled from 21,061 emergency patient reports by 267 emergency departments. The data does not include freestanding emergency centers.
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