Anthem denied roughly 12,200 or 5.8% of all emergency room claims in Missouri, Kentucky and Georgia from July 2017 to Dec. 2017 through their controversial policy of denying payment for ER visits later determined not to be an emergency, according to a scathing report issued Thursday by Missouri Democratic Senator Claire McCaskill.
The majority of ER claims initially denied in those three states from July 2017 to Nov. 2017 were overturned on appeal, according to Anthem data provided to the lawmaker. The rate of overturned denials increased almost every month from an initial 58% in July 2017 to 73% in Nov. 2017. Georgia and Kentucky showed similar average rates of 60% and 70% respectively, suggesting that a majority of initial claim denials were incorrect or overzealous.
Anthem, which did not dispute the report, is now reviewing all denied ER claims since the program’s inception in July 2017, a process which may take several months. The payer significantly revamped its screening process in Jan. 2018, resulting in a substantial decline in claims denials this year.
Anthem’s policy of refusing to pay for non-emergency ER visits — with status determined by the payer retrospectively — was controversial from the start.
The McCaskill report argues that although Anthem has enhanced their ER claim screening process, clarified exemptions and added steps to its review including medical record requests, the payer is still forcing patients to act as their own doctors in determining whether their ailments qualify as an emergency.
The reversal statistics in particular are a point of concern, as the report notes they show Anthem employees may “lack the necessary experience or training to apply ER claims policies correctly in the first instance.” Even after changes to the screening process, the resulting sharp decline in denials suggests the company was “overly restrictive” initially when reviewing ER claims.
The payer reiterated its cost-cutting efforts and commitment to the program, while stressing the tendency of patients to head to the ER for problems that are not emergencies.
“Anthem’s goal is to ensure access to high quality, affordable health care, and one of the ways to help achieve that goal is to encourage consumers to receive care in the most appropriate setting. Anthem’s Avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies,” an Anthem representative wrote to Healthcare Dive via email.
“ERs are often a time-consuming place to receive non-emergency care and, in many instances, can be 10 times higher in cost than urgent care," they wrote. "In general, the denial rate from our program shows that around 5 percent of all emergency room claims are for non-emergency care, which is in line with findings from the Centers for Disease Control and Prevention."
Anthem disclosed to McCaskill their procedures for reviewing ER reimbursement claims. The payer assigns their own specific diagnostic codes — codes not often associated with emergency care — to the visit. If an ER claim contains one of these codes, Anthem flags the case for review.
If the visit doesn’t fit into the “must-pay” category, an Anthem medical director reviews the claim information, then determines whether the symptoms would have led a “prudent layperson to conclude that he or she was experiencing an emergency medical condition,” even if the final diagnosis turned out to be a non-emergency.
Anthem was following this process in 2017 amid the flurry of denied claims that would later be overturned.
Between July and Nov. 2017, Anthem processed roughly 73,000 ER Missouri claims, filtered 7,500 for further review and denied 3,700 — about 5% of all claims in question. They processed 51,000 Georgia claims, filtered 10,000 and denied 3,500 (or 7%). Finally, in Kentucky, Anthem reviewed 117,000 ER claims, filtered 13,000 and denied 5,000 (or 4%).
Yet of the 5.8% of denials in those three states, the majority have now been approved.
According to the data Anthem made available to McCaskill, the payer overturned 62% of initial denials that patients appealed within the five-month period. The report argues the large volume of re-assessments are especially troubling as Anthem places the burden of appeal on beneficiaries who are saddled with the bill as they move through the appeals process.
Ultimately, the provider is sticking with the initiative — with some changes and with the intention of reviewing each denied claim since July 2017, which will take several months to complete.
The changes have resulted in a significant decline in denials since the beginning of 2018. The percentage of Anthem-denied ER claims in Missouri has declined from 0.9% in Dec. 2017 to 0% in March 2018, a decline mirrored in Kentucky and Georgia alike — from 1.2% to 0%, and from 0.2% to 0% respectively.