Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Exploring Anthem’s New Policy for “Non-Emergency” ER Visits

Exploring Anthem's New Policy for Non-Emergency ER Visits

Beginning January 1, 2018, Anthem Blue Cross and Blue Shield began enforcing a new program In Indiana to discourage members with supposed “minor” conditions from going to the emergency department for treatment. That program, announced last summer and originally planned to begin in September 2017, denies payment for emergency department charges for what Anthem considers “non-emergency” conditions and requires patients to pay out of pocket.

To help patients choose what Anthem calls an “appropriate” level of care, they offer a Health Care Services webpage with a continuum of care venues ranging from their telehealth option, Live Health Online, to the emergency department. For each service location type, the tool shows how it compares in cost, wait time, and severity of condition to the others. Anthem also lists possible symptoms that would merit each level of service: with things like rash, minor burns, cough, sore throat, and shots warranting a trip to a retail clinic, and nausea or diarrhea, ear or sinus pain, minor allergic reactions, animal bites, or back pain necessitating an urgent care visit. For an emergency room visit, they simply ask patients to consider whether “you believe your life or health is in danger.”

A Violation of the Prudent Layperson Standard?

The problem with the policy is that patients don’t always know what danger their symptoms may reveal, according to the American College of Emergency Physicians (ACEP). The organization has long held that these kinds of payer programs put patients at risk and are in violation of the prudent layperson standard, which is codified in state and federal law, including the Affordable Care Act.

“Health insurance companies can’t expect patients to know which symptoms are life-threatening and which ones are not, and they shouldn’t be punished financially because of it,” said Purva Grover, MD, FACEP, president of Ohio ACEP.  “Emergency physicians treat patients every day with identical symptoms – some go home, some need a medical procedure, and some need to be admitted. Only a full medical work-up can determine that.”

That’s because there’s nearly a 90 percent overlap in symptoms between emergencies and non-emergencies, said Paul Kivela, MD, MBA, FACEP, president of ACEP, citing a 2013 study in the Journal of the American Medical Association.

In December, Senator Claire McCaskill, D-Mo., sent a letter to Anthem CEO Joseph Swedish asking him to provide information related to this new policy.

“Patients are not physicians. I am concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events,” McCaskill wrote. “State and federal law has codified a ‘prudent layperson’ standard for insurers to use when determining coverage of emergency medical treatment. … Recent reports raise serious concerns with Anthem’s approach to complying with these federal and state laws.”

ACEP also has released a series of YouTube videos lambasting Anthem for the policy, including this week’s “Anthem’s Unlawful Emergency Care Policy Hurts Patients,” which humorously depicts three patients with the same symptoms who end up with very different diagnoses.

A History of Not Paying

This new policy, which is now in effect in six states (Missouri, Kentucky, Georgia, Ohio, New Hampshire, and Indiana), is similar to their ongoing policy of reducing payment for ED services considered non-emergent in their Indiana Medicaid line of products. For Anthem’s Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect plans, the payer uses an ER Auto-Pay List to determine what gets paid and how. If a diagnosis is not on the list, the claim is subject to Anthem’s “prudent layperson review of the medical record.” If upon review Anthem determines that the patient’s condition was not an emergency, then they will reimburse the physician for a screening fee, which is the equivalent of a level 99281 service or around $16.

“Health plans have a long history of not paying for emergency care,” Kivela said. “For years, they have denied claims based on final diagnosis instead of symptoms. Emergency physicians successfully fought back against these outrageous policies. Now, as the future of health care is debated again, insurance companies are trying to reintroduce the practice.”

What You Can Do

The usual recourse for such practices is for the physician or their billing company to appeal the claim. CIPROMS Coding Liaison and Coding Auditor Cara Geary recommends the following documentation best practices to give a full picture during the medical record review and/or the appeals process of how the patient was received and evaluated in the ED:

  • Make a note in the medical record if another medical provider sent the patient to the ED.
  • Record the presence of acute conditions or the acute exacerbation of chronic conditions.
  • Document how chronic or previous conditions influenced medical decision making.
  • Include differential diagnoses, or at least note the patient’s concerns (i.e. “patient was concerned she had another blood clot” or “patient felt like her previous pneumonia where she was hospitalized for 5 days”).

Geary said the last one “makes a strong argument that the patient was seeking the care they felt was most appropriate for their complaints,” which Anthem says is the primary objective of their policy.

Not all non-emergent ER visits will be denied payment by Anthem. According to the insurer, they will continue to cover non-emergent ER visits if any of the following conditions are met:

  • a member was directed to the emergency room by another medical provider,
  • services were provided to a child under the age 14,
  • there isn’t an urgent care or retail clinic within 15 miles of the member, or
  • the visit occurs on a Sunday or major holiday.

For more information about Anthem’s policy, review their original announcement of the policy, a fall update about the rollout of the policy, and their educational flyer for patients.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

© Copyright 2020