Anthem alters controversial ER coverage policies

A lighted emergency room sign outside of a hospital
Anthem's ER coverage restrictions have been criticized by provider organizations. (Getty/MJFelt)

Seeking to address mounting concerns from providers and other stakeholders, Anthem has made changes to policies it previously rolled out that restrict coverage for emergency room visits.

Anthem’s program was meant to deter members from using the emergency room for illnesses or injuries that aren’t life-threatening. But critics say patients shouldn’t be forced to self-diagnose, warning that the new policies will encourage people to avoid seeking care for serious medical conditions out of fear that their claim will be denied.

RELATED: Providers warn Anthem’s ER policy may violate federal law

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In a statement to FierceHealthcare, Anthem said it hasn’t changed its belief that inappropriate ER usage should be curtailed. However, the insurer said it recognizes “that there are ways to further improve and enhance the program.” 

Thus, it has implemented a series of “always pay” exceptions for certain circumstances. These include when the ER visit was associated with an outpatient or inpatient admission, or when the patient received any kind of surgery or an MRI or CT scan.

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Anthem said it will apply these new procedures to previously denied claims and will overturn decisions where the new procedures would have resulted in an approval. The insurer will also request medical records from the hospital as part of its review process.

The changes will primarily affect the three states where Anthem first rolled out its ER coverage restrictions: Kentucky, Missouri and Georgia. Ohio, Indiana and New Hampshire were added to the program in January, after the new exceptions were already in place.

The group that has been most critical of Anthem’s ER coverage policies, however, isn’t satisfied with the changes.

“From ACEP’s perspective, this is still a fundamentally flawed policy,” Laura Wooster, associate executive director of public affairs for the American College of Emergency Physicians, told FierceHealthcare.

For example, while it’s good that patients who are admitted to the hospital as a result of their ER visit won’t have their claim denied, they still won’t know whether they needed to be admitted before being examined by an ER doctor, she said.

“Making fixes around the edges doesn’t end this dangerous policy that’s really going to scare patients away from going to the ER or even considering going to the ER,” Wooster added.

Editor's note: This article has been changed to clarify which "always-pay" exceptions have been newly implemented by Anthem. A previous version of the article listed some exceptions that were already in place.