Anthem Blue Cross expands program that denies claims for unnecessary ED services
Anthem Blue Cross Blue Shield will no longer cover emergency department (ED) services it deems unnecessary in Missouri, reported St. Louis Public Radio.
The payer said an Anthem medical director will review the claims information and decide whether symptoms and diagnosis warranted the ED visit.
Becker’s Hospital Review said Anthem has implemented similar policies in Kentucky and Georgia and is looking to expand to more states, possibly Indiana and Ohio. Anthem said the Kentucky policy has been in place since 2015 and has only denied a small percentage of claims for unnecessary emergency department use.
Anthem is making the change to save costs, as well as cut ED visits and wait times. The payer would rather patients go to less expensive retails clinics and urgent care clinics and use 24/7 telehealth services if they can't see their physicians.
There are now more than 2,300 convenient care clinics in the U.S. after the first one opened in 2000, according to the Convenient Care Association (CCA). CCA said there are clinics in 43 states and Washington, D.C. Payers welcomed the expansion of retail clinics and urgent care clinics as a way to control costs and reduce ED utilization.
But it's not clear that's what happens. A study published last year in the Annals of Emergency Medicine found that, to date, retail clinics "have not been associated with a meaningful reduction in low-acuity ED visits." Hospitals look to their EDs as a strong source of patient admissions, and a 2014 Health Affairs study found the departments had an average profit margin of 7.8%.
The American College of Emergency Physicians (ACEP) did not greet Anthem’s ED policy warmly. ACEP and its Missouri chapter said the policy of rejecting ED claims is a “clear violation of the national prudent layperson standard.” That standard requires payers to cover patients based on a patient’s symptoms and not their final diagnosis.
ACEP said nearly 2,000 non-urgent diagnoses on Anthem’s list of possibly non-covered symptoms can be life-threatening or lead to further health problems.
"Health plans have a long history of not paying for emergency care," said Dr. Rebecca Parker, president of ACEP. "For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law. Now, as healthcare reforms are being debated again, insurance companies are trying to reintroduce this practice."
The ACEP is concerned that Anthem members may delay care because of the new policy.
"If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance," said Parker. "The vast majority of emergency patients seek care appropriately, according to the CDC, and often times should have come to the ER sooner."
Payers are likely watching Anthem’s program to see if it leads to fewer ED visits and lower costs. If Anthem sees savings, more insurance companies may follow suit, which could affect hospitals through fewer emergency patients and more uncompensated care.
Payers have been gently pushing patients toward retail clinics rather than EDs over the past decade. Insurance companies view them as a low-cost alternative that can free up EDs for serious cases. With its policy, Anthem is doing more than giving patients a gentle push.
- St. Louis Public Radio Anthem asks Missourians to think twice before going to the emergency room
- Becker's Hospital Review Anthem extends its discretionary coverage for ER visits to Missouri