Anthem’s policy suggests that patients should diagnose themselves before heading to the ED, or risk an uncovered, potentially large hospital bill. How can the data health insurers already possess help curb unnecessary emergency room visits without putting patients’ lives at risk?

In six states, the major insurance company has been denying claims for emergency department visits AFTER a diagnosis is made, which could put patients’ lives at risk

The health insurance company Anthem Blue Cross Blue Shield (BCBS) has begun denying coverage of what they deem “inappropriate” emergency room visits AFTER a diagnosis is made. This suggests that patients should diagnose themselves before heading to an emergency department or risk a huge, uncovered hospital bill.

What the Policy Means

So far, Anthem’s policy has been implemented in six states: Georgia, Kentucky, Indiana, Missouri, New Hampshire, and Ohio. As of January 2018, the company had denied more than 1,000 claims in Kentucky alone, with some hospitals reporting that the denials are impossible to quantify because their reimbursement systems are not set up for this purpose. The loss is written off instead.

The policy doesn’t apply if patients are 14 or younger, if the visit occurs on a Sunday or a holiday, or if an urgent care clinic isn’t located within 15 miles. They vary by state, but about 1,900 conditions are subject to rejection, including limb injuries and sprains, but also more serious conditions.

Pushback on Policy

Medical experts, including ED physicians and some lawmakers, are worried that Anthem will roll out what the LA Times calls “a manifestly anti-consumer policy” in more states and that more health insurance companies will follow suit. In January, the American College of Emergency Physicians (ACEP) launched a video pushing back on Anthem’s policy. The video explains that people with identical symptoms may have different diagnoses that could be either non-urgent or life-threatening.

ACEP President Dr. Paul Kivela, MD, FACEP, commented on the video, saying that the policy “has deadly serious implications for patients,” and that “Anthem is risking patients’ lives by forcing them to second-guess their medical symptoms before they get to the ED,” noting that some patients may decide not to go when they actually need to.

State regulators are stepping in. In December, Sen. Claire McCaskill, D-Missouri, sent a letter to Anthem CEO Joseph R. Swedish asking for documentation of how the company arrived at its policy and how it is being applied. It’s not clear if Anthem has met the requested deadline of January 19.

Is the Policy Legal?

Anthem’s policy must stand up to two long-standing legal safeguards for patients. The first is the Emergency Medical Treatment and Labor Act (EMTALA), established in 1986, which mandates that anyone going to an emergency department must be stabilized and treated, regardless of insurance status or ability to pay.

EMTALA is a de facto national health care policy for the uninsured and is referred to as the “anti-dumping” law. It was designed to “prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer.” Under Anthem’s policy, however, there is no guarantee that Anthem will pay for their members’ visit if Anthem deems it to be non-emergent.

In addition, the “prudent layperson” rule requires coverage of an ED visit that an average person could reasonably consider a possible emergency. The rule protects a patient’s decision to seek emergency care for a condition he or she deems to be emergent.

Is Anthem’s Policy Saving Money?

Anthem’s justification for the policy is a potential reduction in the number of unnecessary visits to emergency departments, which many in emergency medicine agree have become problematic in recent years. But is the policy saving money? And who benefits?

Scott Richards, CEO of d2i, wonders if Anthem is committed to using their reduced costs to reduce premiums or patients’ out-of-pocket costs:

Anthem is the one saving the money. And they are risking the lives – and the finances – of their members and their members’ loved ones if they don’t make the right decision about what to do when a medical emergency arises. They are putting our country’s health care safety-net providers at risk, too, by sticking hospitals with even more self-pay bad debt than they already have to contend with.

Leveraging Data for Better Patient Care

Richards called the policy an unfair practice and believes that there are other ways to accomplish Anthem’s goal without alienating their members and punishing our country’s safety net.

Instead of focusing on patients who make a decision to visit an ED for what they believe is an emergency, he said, there is more opportunity to impact the inappropriate use of emergency departments by “managing frequent users of these services into alternative, lower-cost care settings.” Richards said the same information Anthem is using to justify denials could be used for these alternatives:

Why not place the same claims and medical record information being used for denial decisions in the hands of their case managers? Using the data insurers already have, they can then identify members who are frequent users of emergency department services and actively engage them to seek care for non-emergent visits from providers in their network.”

At d2i, we believe insurance companies like Anthem should be using all the patient data they have to help curb unnecessary emergency department visits by identifying their members who historically use the ED for non-emergent issues by connecting them to alternate providers or treatment options. Such an approach not only ensures patients receive the right care in the right place when they need it but also helps hospitals optimize ED performance and improve the quality of care they provide.