Atlanta-based Piedmont Hospital and five sister facilities are suing Blue Cross Blue Shield of Georgia and its parent company, Anthem, after the payer stopped paying for imaging in hospitals and emergency department (ED) visits that weren't deemed an emergency. Northeast Georgia Health System is also suing in a similar case.
In the Piedmont lawsuit, the hospitals charged that the payer is involved in “a national scheme” geared to “intentionally deteriorate coverage for policyholders.”
The hospitals also said the policies are trying to reduce costs that will have “harmful consequences on access to medically necessary services, clinical integration, patient safety and quality of care.”
The imaging and ED policy changes are part of Anthem’s effort to move care into less expensive, but still appropriate locations. Anthem’s cost-cutting policies have caused opposition from providers and hospitals, but Lori McLaughlin, Anthem communications director, recently told Healthcare Dive that getting services in a “clinically appropriate setting” will result in lower healthcare costs for members and the healthcare industry overall.
“Anthem’s primary concern is to provide access to quality, safe and affordable healthcare for our affiliated health plan members. We’re always looking at new approaches to ensure clinical quality and improve affordability and we are committed to reducing overall medical cost where possible when the safety of the member is not put at risk,” she said.
Other payers are watching Anthem’s policies and related backlash closely.
“Will Anthem get a lot of pushback from patients and employers? Will hospital lobbies succeed in getting state governments to force Anthem to roll back the policy? If Anthem does not face, or successfully overcomes, these types of challenges, other payers may very well follow suit,” Lea Halim, senior research consultant at the Advisory Board, recently told Healthcare Dive.
It’s not just EDs and imaging where Anthem sees a way to reduce costs. Anthem is also cutting provider payments by 25% for separate evaluation and management (E/M) services billed by CPT modifier 25 when physicians provide services on the same day of a procedure or other service.
Anthem will start the 25% reduction on March 1 in 12 states and further expand it to Georgia and Virginia after network contract renewal. Anthem said it doesn't expect physicians “to modify their approach to delivery services,” but critics say the cut may cause providers to delay additional patient care. That could then cause patients to not get the care because of the hassle of returning on another day.
AMA President David Barbe called the payment cut “unfair” and “detrimental to physicians who are trying to practice medicine according to the needs of their patients.”
“Health insurers that reduce or deny payment for evaluation and management services associated with procedures performed on the same day are needlessly forcing patients into multiple visits and delaying the provision of necessary care,” he said.