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Anthem’s New Policy: A Recipe for Delayed Treatment and Unpaid ER Bills?

by Kate Gray on January 23, 2018 at 3:20 PM


For the states of Georgia, Missouri, and Kentucky, a newly-implemented Anthem policy indicates that patients will no longer be covered for non-emergency medical conditions treated in the emergency room (ER). Anthem stresses insurance will continue to cover emergency conditions and that this policy only applies to non-emergency conditions that are best treated by a primary care physician.

Although this policy is intended to address the overuse of ERs, promote appropriate care settings and deter use of the ER as primary care by many, there are several concerns that have been raised regarding the new principle. In particular, the American College of Emergency Physicians (ACEP) objects to the new policy based on the fact that, in the majority of situations, neither patients nor doctors can truly know the severity of presenting symptoms until further evaluation. Simple chest pain could be indigestion, but further analysis could determine that a heart attack is actually occurring and immediate intervention is required.

Further, Vidor Friedman, MD, vice president of ACEP, believes that Anthem’s policy violates the Affordable Care Act’s prudent layperson standard: a standard requiring insurance companies to cover emergency care based on a patient’s symptoms and not a patient’s final diagnosis. Patients do not have the ability to—nor should they be expected to—distinguish between difficulty breathing from pneumonia or from a pulmonary embolism. Yet, Anthem has a list exceeding 1,900 ICD-10 codes that are no longer covered for an ER visit, and this list not only includes chest pain on breathing, but it also includes symptoms such as a cough and pain in a leg.

Negative Implications to Patient Care

Rebecca Parker, MD, immediate past president of ACEP, poses an even more critical view on the policy because of its potential implications regarding patient care. Due to the overlap between the symptoms for emergency and non-emergency conditions, which is estimated to be roughly 90% per the Journal of the American Medical Association, this policy runs the risk of steering patients away from the ER when they otherwise would have gone in for treatment. This practice could be dangerous, deterring critical patients from seeking care for fear of non-coverage.

Research supports Parker’s concerns. On ACEP’s behalf, Morning Consult conducted a poll and discovered that 43% of people interviewed either delayed or avoided emergency care due to cost concerns. When considering that only 3.3% of all ED visits are avoidable, this fact is quite alarming and has a high possibility of being detrimental to an individual’s health (International Journal for Quality in Health Care).

Negative Implication to Patient Bills

Aside from the damaging impact this policy could have on patients’ health, a similar damaging impact may be seen on patients’ budgets. If Anthem decides a patient’s decision to use the ER was not appropriate, they will not be paying for the visit. The patient, then, is going to be expected to foot the bill. Emergency room visits can be close to $500, and that’s without a hospital’s facility fee included. Patients are likely going to find this sudden burden of payment overwhelming, and it may result in unpaid bills. Unpaid bills not only hurt the hospital and physician groups, but they can also drive prices up even further for others as a compensatory mechanism, in order to make up for the mounting number of unpaid bills.

Moving forward, it is going to be imperative to speak up against policies that are in violation of existing legislation. Speaking out about Anthem’s new coverage terms is one way to make voices heard.

For more on Anthem’s new policy and how you can get involved, please visit www.faircoverage.org.

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This post was written by Kate Gray

Kate Gray is a Senior Financial Analyst at Intermedix. She has been with Intermedix for over two and a half years. Prior to joining Intermedix, Gray held a research associate position at a clinical-stage pharmaceutical company. Gray earned her bachelor’s degree in biology at Wake Forest University.

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