ED Coding and Reimbursement Alert

Physician groups, lawmakers fight against expanded policy.

Private insurer Anthem Blue Cross Blue Shield is expanding its controversial policy of denying ED claims for conditions that Anthem labels "non-emergent." The policy, which was initially launched in Missouri, Georgia, and Kentucky, has also rolled out to patients in Ohio, New Hampshire, and Indiana.

The company is essentially asking patients to make self-determinations of their diagnoses after evaluating their conditions. "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 an asthma attack and the ED physician diagnoses him with seasonal allergies, that could be a reason for denial, since "seasonal allergies" is among the "non-emergent" conditions Anthem lists on its website.

At issue, however, is the ability of patients to use "the prudent layperson standard" to make diagnostic determinations, opponents of the policy say.

"Anthem's policy has deadly serious implications for patients," said Paul Kivela, MD, FACEP, president of the American College of Emergency Physicians (ACEP), in a Jan. 19 news release. "Anthem is risking patients' lives by forcing them to second guess their medical symptoms before they get to the ER, and some may not go when they need to." ACEP has released a video explaining the overlap between emergent and non-emergent conditions. "Insurers cannot reasonably expect patients to know the difference," Kivela said.

In addition, many lawmakers are fighting back against the policy. In December, Missouri Sen. Claire McCaskill sent a letter to Anthem CEO Joseph R. Swedish asking for information about the controversial policy. "I am concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events," McCaskill wrote. "Missouri state law and federal law protect patients from having to make these types of medical decisions. Lawmakers have recognized it is unreasonable and unfair to expect patients to have the same knowledge as doctors and be able to distinguish between the chest pain caused by indigestion and chest pain causes by a heart attack."

Resources: To read Kivela's press release, with information for ED physicians, visit http://newsroom.acep.org/2018-01-17-Emergency-Physicians-Expose-Anthems-Harmful-Emergency-Care-Policy-With-New-Video. To read Anthem's post on emergent vs. non-emergent conditions, visit https://www.anthem.com/blog/member-news/finding-the-right-care-when-not-an-emergency/.