Anthem’s ER policy continues to raise ire of physicians, senator
THE FIRESTORM over Anthem’s policy to deny coverage for certain emergency department visits continued last week as physician groups took the insurer to court and a key congressional critic released a report analyzing the impact of some of those denials.
A report from Sen. Claire McCaskill (D-Mo.), who has been a thorn in the insurer’s side since news broke of the controversial policy, found that there was a spike in coverage denials among ED patients in Georgia, Kentucky and Missouri last year. But Anthem ended up reversing the majority of denied claims that patients appealed.
That means “a significant percentage of initial denials were improper—a troubling result given that Anthem places the burden of appeal on beneficiaries, and individuals without the time and resources to file an appeal may face a significant and potentially improper financial responsibility,” McCaskill’s report stated. The report concluded that Anthem employees may not have appropriate training or experience to carry out the ED policy.
Responding to the report, an Anthem spokeswoman said via email that during the appeals process, plan members often provided additional information that resulted in the company overturning its decision to deny the claim.
A spokesman for McCaskill’s office said there were many denied claims that were not appealed and thus, not overturned.
Anthem rolled out the policy across several states in 2017 and more this year. It denies reimbursement for visits that the insurer determines after-the-fact were not real emergencies.
“The problem is we don’t know how many (patients) didn’t go to the ER because they’re afraid of the financial penalty,” said Dr. Vidor Friedman, president-elect of the American College of Emergency Physicians.
The ACEP, along with the Medical Association of Georgia sued Anthem’s Georgia subsidiary July 17 in a bid to force the insurer to end the policy. It’s not the first legal challenge to the policy.
Piedmont Hospital and five sister hospitals in February sued Anthem Blue Cross and Blue Shield of Georgia claiming the policy violates Georgia law. But while Anthem tweaked the ED program in February in response to outrage from state legislators and the public, it has refused to rescind it.
“This is a first step in the process and depending on how things play out, we would entertain filing in other states where Anthem is (implementing) the policy,” Laura Wooster, associate executive director for public affairs in ACEP’s Washington office, said regarding the lawsuit.
Anthem’s ED policy is active in six states. The ACEP filed its first suit in Georgia because the state’s medical association came forward as a potential part- ner in a lawsuit, Wooster said.
The lawsuit filed in federal court in Atlanta alleges that Anthem’s ED policy harms healthcare providers and their patients. Anthem is denying providers the reimbursement they are owed for providing emergency services and causing providers to spend time and effort responding to “inappropriate denials,” the suit alleged. Anthem decides whether to deny or pay for emergency care based on a list of diagnostic codes that it won’t publicly release. It wouldn’t provide those codes to McCaskill either. Emergency doctors argue that basing coverage decisions on final diagnostic codes included in a claim disregards the symptoms and other circumstances surrounding a patient’s decision to go to an ED.
“They are asking patients to diagnose themselves, and that’s just not appropriate,” Friedman said.
Back in December, McCaskill sent a letter to then-Anthem CEO Joseph Swedish demanding information on the policy. The report’s findings are based on the information Anthem and others provided as part of her inquiry.
According to the report, Anthem denied approximately 12,200 emergency claims in Missouri, Kentucky, and Georgia from July 2017 through December 2017. That’s about 5.8% of all ED claims submitted from those states during that period.
In Missouri, Anthem later overturned about 62% of initial claim denials that were appealed between July 2017 and November 2017. Similarly, Anthem reversed 60% of denied claims that were appealed in Georgia, and 70% in Kentucky.
It’s unclear, though, how many patients appealed their denied claims.