ED Coding and Reimbursement Alert

New analysis takes new look at Anthem’s controversial program.

Wondering how rampant Anthem’s denials could get under its new policy? A new study reveals that if other insurers implement the same program, emergency department denials would soar.

Background: Anthem has a policy impacting patients in select states in which the payer will deny ED claims for conditions that Anthem labels “non-emergent.” The policy requires patients to personally determine whether their diagnoses are true emergencies, which can be challenging when patients have symptoms that could be of serious, emergent conditions or could be something more minor.

“If you chose to receive care for non-emergency ailments at the ER when a more appropriate setting is available, your claim will be reviewed using the prudent layperson standard and potentially denied,” Anthem writes on its website. “The review by a medical director will take into consideration the symptoms that brought you to the emergency room even if the diagnosis turned out to be a non-emergency ailment.”

If, for example, a patient believes he is having a heart attack and the ED physician diagnoses him with heartburn, that may be a reason for denial. At issue, however, is the ability of patients to use “the prudent layperson standard” to make diagnostic determinations, opponents of the policy say.

Study Extrapolates Findings Out to All Payers

Researchers from the Department of Emergency Medicine at Brigham and Women’s Hospital in Boston evaluated ED visits across the country and determined what would happen to claims for those encounters if all payers adopted policies similar to Anthem’s. The findings, which were published in JAMA Network Open on Oct. 19, revealed that if other payers were to adopt the same policy as Anthem has, “nearly one in six ED visits by commercially insured adults would have a nonemergent ED discharge diagnosis and could be denied coverage.”

Interestingly, in up to 90 percent of adult-aged commercially insured ED visits, “patients presented with the same primary symptoms as the visits that resulted in nonemergent diagnoses that could be denied coverage,” the study determined. “Even among patients with potentially life-threatening symptoms such as chest pain, who would likely be instructed to seek emergency care if they consulted outpatient clinicians, up to four percent may be denied coverage and possibly receive an uncovered medical bill.”

The study concluded that Anthem’s policy was not effective in identifying unnecessary ED visits when evaluated from the perspective of the patient. “This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial,” the report noted.

The policy, which is on the books in six states, is still under fire by both medical organizations and patients, but Anthem has not yet rescinded it. In July, the American College of Emergency Physicians and the Medical Association ofGeorgiafiled a federal lawsuit challenging the policy. “Patients should never hesitate to seek emergency care out of fear of getting a large bill,” said Frank McDonald, MD, MBA, president of the Medical Association of Georgia.

ED Coding Alert will continue to follow this issue to determine whether any changes are made, so keep an eye on future articles to stay on top of the topic.

Resource: To read the entire study in Jama Network Open, visit https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707430.