Report: ER claims denials spiked in 3 states following Anthem’s controversial policy

A lighted emergency room sign outside of a hospital
ER claims denials spikes last year following Anthems new policy, but then dropped sharply this year following changes to the program. (Getty/MJFelt)

Anthem’s ER claims denials increased sharply last year following an announcement that the insurer would restrict coverage for what it deemed to be nonemergent visits.

But those denials have plummeted this year after Anthem scaled back its policy following blowback from physician groups and lawmakers, according to a new report.

The report, released by Sen. Claire McCaskill, D-Mo., on Thursday, also shows the insurer overturned the majority of its denials during the initial rollout of the program, an indication that many of those claims were denied in error. McCaskill released the report based on data provided by Anthem following her request for information late last year.

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According to the report, Anthem denied more than 12,000 ER claims in Missouri, Kentucky and Georgia between July 2017 and December 2017, representing 5.8% of ER claims. The rate of denials spiked in the months after Anthem announced a new policy to review ER claims for nonemergent services, but then tapered off from January 2018 through March 2018 after Anthem altered its policy by expanding its list of “always pay exceptions.”

RELATED: Anthem alters controversial ER coverage policies

“This appears to have been an example of an insurance company looking for ways to save a buck at the expense of their patients, only to then reverse course to try and save face once folks noticed and called them out—and I will continue digging in to make sure this reversal is not short-lived,” said McCaskill.

Notably, the percentage of claim denials that were overturned after appeal increased between July 2017 and November 2017, reaching 79% in both Kentucky and Georgia.

“These findings indicate Anthem may have pursued an overly restrictive initial approach to reviewing ER claims and may have failed to equip employees with the proper training to apply company policies correctly,” the report stated.

The report comes days after the American College of Emergency Physicians (ACEP) and the Medial Association of Georgia sued Anthem over its new policy, arguing that it violates federal law. McCaskill’s office reviewed data from three states where the policy was initially rolled out. Anthem has since implemented the policy in three additional states—Indiana, Ohio and New Hampshire.

RELATED: Emergency physicians sue Anthem over ER policy change

In a statement to FierceHealthcare, Anthem said the program’s denial rate aligns with findings from the Centers for Disease Control and Prevention (CDC) that shows 5.5% of all ER visits are for non-urgent care. The insurer said the policy changes are meant to “encourage consumers to receive care in the most appropriate setting” and reduce that trend of inappropriate ER usage which comes at a significantly higher cost.  

“Anthem is committed to our avoidable ER program because the costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the healthcare system as a whole,” the company said in a statement. “Anthem has made, and will continue to make, enhancements to ensure consumers are receiving the right care at the right place and time.

“Anthem announced earlier this year that we are applying the new and enhanced procedures to previously denied claims and will overturn decisions where the new procedures would have resulted in an approval. Over the past several months, we have been focused on the re–review process and putting the enhancements in place.”

The policy has caused significant blowback from provider groups and some lawmakers. McCaskill has emerged as a leading critic of the insurer’s policy, issuing a letter (PDF) to Department of Health and Humans Services Secretary Alex Azar in March, asking him to look into Anthem’s ER policy and potential violations of federal law.