Anthem's aggressive moves to push procedures like imaging to outpatient settings and taking a hard line on emergency room visits has drawn fire from doctors and other critics.
Researchers in JAMA earlier this month wrote that if a similar Anthem policy were widely adopted by other commercial payers then as many as 1 in 6 patients could be denied coverage for seeking care in the ER.
"This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial," the JAMA authors wrote.
Here's a timeline of the moves of the second biggest U.S. health insurer, the reaction and impact.
May - Anthem began warning some members that it would no longer pay for ER visits that were later deemed a non-emergency by the insurer, calling it needed due to a spike in what they consider unnecessary emergency visits. The policy seeks to change patient behavior and steer them to less-expensive venues, but some worried it would have a chilling effect on members who forgo needed care because of the fear they'd later be on the hook for the entire bill. Anthem had initially rolled out the ER policy in Kentucky in 2015 and has since expanded in to four other states: Missouri, Georgia, Ohio and Indiana.
July - Anthem said it would no longer pay for certain outpatient imaging at hospital-owned facilities due to significant cost variation between them. That move was a win for the less-expensive freestanding facilities that are likely to see increased volume. There are some exceptions to the rule, such as if a person is experiencing an emergency and needs a particular scan. The policy was initially implemented in just a handful of states.
Feb. 13 - Atlanta-based Piedmont Hospital and five sister facilities sued Blue Cross Blue Shield of Georgia and its parent company, Anthem, after the payer stopped paying for imaging in hospitals and emergency department visits that weren't deemed an emergency. Two months after filing a lawsuit against the insurer, Piedmont and Anthem could not agree to contract terms, putting thousands of patients out-of-network. The governor of Georgia threatened to intervene if the two could not come to terms. A deal was reached in April and the lawsuit was voluntarily dropped. Northeast Georgia Health System is also suing in a similar case.
Feb. 16 - Facing backlash, Anthem added some exceptions to its policy of denying emergency department claims it later deems medically unnecessary. Anthem said it would pay for ER visits when a patient is referred by a provider and when a patient is out of state, in addition to other exceptions.
Feb. 23 - After pushback from the American Medical Association, Anthem canceled plans to cut provider reimbursement by up to 25% for evaluation and management services when a different service is performed that same day. AMA said the move could increase costs, delay care and force patients to return for unnecessary visits.
March 8 - UnitedHealth Group is looking to cut down on expensive ER claims under a new policy that took effect March 1, Modern Healthcare reported. The move follows Anthem's controversial policy to curb ER costs and utilization among its members in certain states.
June 5 - Blue Cross and Blue Shield of Texas delayed the ER policy for 60 days after intense criticism from physicians and the state's insurance department. After working out "sticking points" with the department, the policy went into effect in August, the Houston Chronicle reported.
June 12 - Saint Joseph Health System in Mishawaka, Indiana, has not been able to negotiate new terms with Anthem because it objects to the payer’s policy of rejecting emergency department claims it reviews and finds were not medically necessary. The two were later able to reach an agreement, according to the South Bend Tribute.
July 17 - The American College of Emergency Physicians and the Medical Association of Georgia filed suit against Anthem's Blue Cross Blue Shield of Georgia in connection to the controversial ER policy. The suit alleges the policy violates the prudent layperson standard, prudent layperson standard, which requires payers cover ER care based on the patient's symptoms and not the ultimate diagnosis.
A report from Sen. Claire McCaskill, D-Mo., cast doubt on the effectiveness of the program from the patient's perspective.
Anthem denied coverage to 12,200 ER claims in three states between July 2017 and December 2017. Anthem almost always reversed its initial decision to deny payment after patients challenged those denials, according to the report.
However, Anthem expected the policy to result in annual cost savings of almost $3 million per year in Missouri alone, McCaskill's report found.
It's still unclear whether Anthem's controversial policies will be adopted more widely by other insurers looking to find leverage to push back against provider pricing.
Meanwhile, providers are pursuing M&A in an attempt to gain the upper hand. Consolidation in Illinois and Texas alone have created behemoth regional players.