Healthcare provider groups take aim at Anthem's ER, imaging coverage policies

Emergency room doctor physician stethoscope scrubs Getty/gordonsaunders
Emergency room doctors and other healthcare providers aren't happy with some of Anthem's recent policies. (Getty/gordonsaunders)

Healthcare provider groups are hitting back against new policies from Anthem that they claim will harm both patients and physicians.

In a letter sent this week to Anthem Executive Vice President and Chief Clinical Officer Craig Samitt, M.D., the groups outline their "deep concerns" with two recently enacted policies and one that’s forthcoming.

The policy that has gotten the most attention is Anthem’s move to deny coverage for visits to the emergency room for injuries or conditions that aren’t actually emergencies. In addition to expressing its concerns about the policy in the letter, the American College of Emergency Physicians released a video slamming the policy, which the group says risk patients’ lives by forcing them to second-guess their symptoms before going to the ER or avoid getting treated entirely for fear their visit won’t be covered.

Innovation Awards

Submit your nominations for the FierceHealthcare Innovation Awards

The FierceHealthcare Innovation Awards showcases outstanding innovation that is driving improvements and transforming the industry. Our expert panel of judges will determine which companies demonstrate innovative solutions that have the greatest potential to save money, engage patients, or revolutionize the industry. Deadline for submissions is this Friday, October 18th.

“I went to medical school, but that doesn’t mean that I can tell by just looking at you whether you can go home or whether I need to do surgery to save your life,” says one doctor featured in the video.

“So why does your insurance company think you know what’s an emergency and what’s not?” adds another doctor.

ACEP and its fellow provider groups also take issue with Anthem’s new policy aimed at steering patients toward freestanding imaging centers—rather than hospitals—for services like CT scans or MRIs.

“This policy disrupts ordering physicians’ relationships with radiology practices, dramatically reduces patients’ options as to where to have their imaging studies performed and removes radiology from the continuum of patients’ care by carving out these life-saving services as a commodity, going to the lowest cost provider,” the groups’ letter states.

Finally, the organizations urge Anthem not to follow through on its plan to reduce physicians’ reimbursement when they bill for both a procedure and an “evaluation and management” visit on the same day. The new policy, which is set to go into effect starting March 1, ignores the common practice of physicians being able to bill for two separate services they perform in the same patient visit, according to the letter.

The groups want Anthem to both rescind the policies in question and engage the provider community “in a concerted, serious dialogue on how to best deliver medical care in a cost effective and efficient manner.”

In response to the groups' concerns, Anthem said in a statement that it does "encourage consumers to receive care in the most appropriate setting" as part of its effort to make care more affordable. 

"As part of that effort, we are constantly evaluating both the effectiveness and appropriateness of our policies to take into account new clinical and technological advancements to ensure that the care is based on peer-reviewed medical evidence and at the best value," the company added.

Editor's note: This article has been updated to include a statement from Anthem.

Suggested Articles

As drugmakers face billions in legal settlements and judgments, we must keep our eye on what will truly defeat the opioid crisis.

As the public debate on health reform rolls on, a new report analyzes how these different approaches could impact insurers' bottom lines.

A House panel is going to consider several changes to Nancy Pelosi's drug prices plan, including stiff penalties for not being transparent.