Anthem's 'retrospective denial' policy for emergency care puts patients at risk: study

empty ER room at a hospital
By retrospectively reviewing diagnoses from the emergency room, Anthem then denies claims it considers to be unnecessary ER visits. (Scott & White Healthcare/CC BY-SA 2.0)

Anthem's policy of "retrospectively denying" emergency department claims has sustained a barrage of attacks from providers, and a new study is giving further weight to those criticisms with evidence that the policy risks discouraging all ER visits, even true emergencies.

The study, published last week in JAMA Network Open, found that based on a review of ED diagnoses between 2011 and 2015, 1 in 6 commercially insured adult ED visits would be classified as "nonemergent" under Anthem's policy. Those denial diagnosis visits shared the same symptoms as 88% of commercially insured adult ED visits. 

"This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial," the study authors wrote.

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Anthem has justified its policy as a way to reduce unnecessary ER visits. By targeting diagnosis codes it determined to be nonemergent, the insurer hoped to divert those ER visits to less-expensive forms of healthcare such as retail clinics.

But that justification hasn't convinced critics, who argue that the average patient wouldn't be able to distinguish emergencies from "nonemergent care situations" without trained medical help. After the insurer implemented the policy last year, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia filed a complaint in a U.S. District Court in Atlanta.

RELATED: Emergency physicians sue Anthem over ER policy change

“We can’t possibly expect people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix,” ACEP President Paul Kivela, M.D., said in a statement.

The study authors said the effect of retrospective denials on ER use hasn't been directly studied. But the mechanism is clear; other cost-sharing policies, such as copayments and high deductibles, have been shown to decrease both high-severity and low-severity ER use.

"In contrast to copayments or high deductibles, diagnosis-based coverage denial poses a financial disincentive that further adds an element of uncertainty," they wrote. "As a result, patients with acute illnesses are put in a difficult position of weighing the risk of delayed treatment for severe disease vs an uncovered medical bill."

RELATED: NYC Health + Hospitals seeks an additional $28.6M from UnitedHealthcare in wrongful claim denials

In an editorial accompanying the study, Maria Raven, M.D., an ED physician with the University of California San Francisco that has authored previous studies on the issue of retrospective ED denials, wrote that "pushing people out of our nation’s EDs is myopic" and called Anthem's policy an "unfair burden on patients."

"Discouraging people from seeking needed care will lead to higher downstream costs for untreated illness and defeat the insurer’s (misguided) attempt to lower health care expenditures," she wrote. 

So far, Anthem's ED policy has been limited in scope. The insurer ultimately denied between 4% and 7% of ED visits in 2017 (after reviewing 10%-20% for denial), according to a probe (PDF) conducted by the office of Sen. Claire McCaskill, D-Mo. But observers including ACEP and the AMA are worried that Anthem will scale the policy in future years.

Although Anthem has taken the brunt of the backlash against such policies, it's not the only insurer to rely on retrospective ED reviews. NYC Health + Hospitals is trying to claw back more than $40 million in improperly denied payments, primarily associated with ED coverage.