Anthem ED policy a sticking point in Indiana contract dispute
Saint Joseph Health System (SJHS) 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 health system mailed a letter to patients warning they could soon face out-of-network costs if it does not agree to new terms with Anthem by the end of the month.
- In its letter to patients, SJHS said the new ED policy restricts patient choice and unfairly puts costs onto patients. The system called the cost-cutting measure “objectionable and the likely consequences of its adoption to be potentially harmful.”
The SJHS contract covers Mishawaka Medical Center, Plymouth Medical Center and VNA Home Care and involves patients with employer-sponsored, Medicare Advantage and Medicaid Anthem plans.
SJHS asked patients to contact Anthem and ask that the payer “continue its partnership” with the system.
“We have asked Anthem to join us in answering the call to care for this community and not further eliminate the choices you have in selecting where you receive care. We have asked Anthem not to require patients to act as medical professionals when they are experiencing emergency medical events and determining where to seek treatment,” SJHS wrote.
The Blues payer has similar ED policies in six states, and says they are a way to reduce emergency services and lead patients to lower-cost facilities, such as urgent care centers, retail clinics and primary care providers.
After pushback earlier this year, Anthem added exceptions to the ED policy, including for patients sent to an ED by a provider, those who are from out of state or go to the ED on a weekend and patients who end up receiving certain medical care, such as surgery, IV fluids or an MRI or CT scan.
Anthem’s policy is not the only one targeting emergency care costs. Blue Cross and Blue Shield of Texas is planning a similar policy it had hoped to launch this month. The payer decided to push back the launch until August after the Texas Department of Insurance voiced concern.
The nation’s largest private payer, UnitedHealthcare, also created an ED cost-saving policy. However, that policy penalizes hospitals that misidentify claims as the most serious conditions evaluation and management codes in commercial and Medicare Advantage plans.
Also, Kentucky’s Medicaid program will soon begin to penalize patients who visit an ED without an emergency health problem. Starting in July, Medicaid recipients who receive care through Medicaid expansion will need to pay between $20 and $75 for visiting an ED for non-emergency care.
Payers, who continue to look for ways to cut healthcare costs, especially high-cost services in EDs, are watching the Anthem situation closely to see whether more health systems follow SJHS' lead and whether that opposition will be enough to cause Anthem to further rethink its policy.
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