Providers warn Anthem’s ER policy may violate federal law

anthem
Anthem's new ER claims policy could violate federal law, providers say. (Matthew Hurst / CC BY-SA 2.0)

Anthem is rolling out restrictions on what it will cover for emergency room visits, but providers worry that the policy could cause patients with potentially life-threatening conditions to avoid care—and that the hard-line approach could violate federal law. 

Anthem has deployed a reduced ER coverage policy in several of its state subsidiaries in regions that include Indiana and Missouri. The insurer said it will deny claims for minor injuries or conditions, like cuts and bruises, swimmer’s ear or athlete’s foot, that bring people to the emergency department, reports the Indianapolis Business Journal.

But physicians in those states worry that patients with potential dangerous symptoms, such as chest pain, may avoid care because they fear higher bills. Missouri provider groups, including the Missouri Hospital Association, the Missouri College of Emergency Physicians and the Missouri State Medical Association filed a letter (PDF) urging the state’s insurance commissioner to take a look at the policy.

“We see the Anthem policy as a cost-shifting tactic that will have a dangerous chilling effect on patients,” they wrote. “When policyholders learn that they might be held financially responsible for emergency department care, we worry some will delay or altogether forgo seeking vitally important and life-saving care at a time when they are most critically ill and vulnerable.”

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Anthem maintains that the policy is designed to curb unnecessary ED use, which is a significant financial drain on the healthcare system.

Joseph Fox, M.D., the insurer’s medical director for its Indiana operations, told the IBJ that nearly three-quarters of ER visits are for nonemergencies, and despite prevention and outreach efforts, the number of visits for emergency care continues to climb between 4% and 8% each year. He said the payer has cut down the number of codes it will reject to a list of about 300 so that patients don’t fear visiting the ER if they really think it’s needed.

In Indiana, where Anthem dominates the market, he estimated that about 8% of visits would be flagged for review under the policy, and about 4% of claims would likely be rejected.

“It’s not a draconian program that we’re rolling out here,” Fox said. “We don’t want that to be misunderstood or misconstrued.”

State and federal laws abide by the “prudent layperson” standard, in which payers are required to cover emergency care for patients who feel their symptoms warrant immediate attention. In the letter, the groups argue that Anthem’s policy violates this standard, and “creates an untenable situation that is at best unfairly punitive, and at worst unacceptably harmful to patients.”

The American College of Physicians expressed similar concerns earlier this year when the policy was rolled out in Missouri. The group notes that a number of the some-2,000 conditions that Anthem would deem “non-urgent” could significantly harm patients.

Anthem’s ER policy is yet another example of payers trying to avoid paying for emergency care,  Rebecca Parker, M.D., president of ACEP said in a statement.

"For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law,” Parker said. “Now, as healthcare reforms are being debated again, insurance companies are trying to reintroduce this practice."