- Anthem has added some exceptions to its policy of denying emergency department claims it later deems medically unnecessary, the payer confirmed this week.
- The exceptions include patients sent to an ER by a provider, those who are from out of state or go to the ER on a weekend and those who end up receiving certain medical care, like surgery, IV fluids or an MRI or CT scan.
- The exceptions went into effect Jan. 1 for all six states in the Anthem program. In the three states where the program had already existed — Kentucky, Missouri and Georgia — Anthem will apply the new procedures “to previously denied claims, and will overturn decisions where the new procedures would have resulted in an approval.”
Anthem said in a statement to Healthcare Dive its goal is still encouraging people to get care in the most appropriate setting. “Anthem stands by our belief that emergency rooms are an expensive place to receive routine care,” the statement read. “The costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the health care system as a whole.”
Providers have fiercely pushed back against the program. They say it forces patients to make decisions doctors should be making and could cause people to delay or avoid needed care. ER services are lucrative for hospitals, which face growing competition for retail clinics and urgent care centers.
A few hospitals are taking Anthem to court over the ER program. Atlanta-based Piedmont Hospital said in its lawsuit the program is geared to “intentionally deteriorate coverage for policyholders.”
Anthem has said its program denies a small percentage of claims, but the change in policy signals the payer may be worried about the backlash, including from patients who have gone public with denied claims.
Anthem has pursed other ways of attempting to cut back costs, including a policy to not pay for MRIs and CT scans performed on an outpatient basis at hospitals and a decision to cut provider payments by 25% for separate evaluation and management services on the same day as a procedure or other service. Both policies are set to go into effect in about a dozen states March 1.
Additional exceptions to the ER program include patients:
- Younger than 15
- Who live more than 15 miles from an urgent care center
- Whose visit was billed as urgent care
- Whose visit is associated with an outpatient or inpatient admission