Emergency Physicians Push Back Against Anthem ED Policy

Alicia Ault

October 11, 2017

The American College of Emergency Physicians (ACEP) is stepping up its opposition to a policy instituted in three states by Anthem Inc, saying that it inhibits people from seeking emergency care and violates the "prudent layperson" standard.

"Health insurance companies are scaring people away from emergency departments, saying they will decide after the fact what is a real emergency," said ACEP President Rebecca Parker, MD, in a statement

Noting that insurers like Anthem may decide after the fact to not pay for an emergency department (ED) visit, Dr Parker said, "These new actions violate federal law and are dangerous, because people with identical symptoms — such as abdominal or chest pains — may either have a deadly medical condition or a non-urgent issue. It is not fair for health insurers to expect patients to know the difference between a heart attack and something that is not life threatening."

ACEP released a poll on October 10 showing that 49% of respondents said they would strongly oppose and 18% would somewhat oppose one major health insurance company's "policy in several states to sometimes deny coverage for emergency care when the final diagnosis turns out to be non-urgent."

While opposed to denials in theory, it appears that few of those polled had a claim rejected for an ED visit. Even so, the fear seemed to be real. Thirty-two percent of the 2200 adults polled — by Morning Consult for ACEP — said they had delayed or avoided emergency care out of fear that their insurer might not cover the visit.

When asked whether they are more likely now than a year ago to delay or avoid emergency care out of concerns about the cost of a copay, coinsurance, and/or health insurance deductible, 51% said they were somewhat or much more likely to have delayed, and a fifth said that their medical condition had gotten worse as a result.

Anthem Policy a Flashpoint

ACEP has fought against insurers — and state Medicaid programs — that have attempted to limit ED utilization, in part because the Emergency Medical Treatment and Labor Act (EMTALA) requires the ED to treat all comers. And, the prudent layperson standard — which says that a prudent layperson without a medical degree would know that without immediate medical attention they could expect a serious impairment — is essentially the law of the land, incorporated into the Affordable Care Act, federal health plans, Medicare, and Medicaid and is codified in 30 state laws.

In 2015, Anthem, one of the nation's biggest insurers, covering 40 million people, instituted a new policy in Kentucky for all of its insured, including large groups, individuals, preferred provider organizations, health maintenance organizations, and other plans. The company said it would review ED claims that appeared to have nonurgent diagnoses and deny payment for those determined to be nonurgent.

The policy is now also in effect in Missouri for all plans and in Georgia for individuals. Anthem is instituting the same policy in Indiana starting in 2018 and may expand it to some of its 11 other state markets. The company is "still evaluating what markets we may bring this program to and don't have any specific timeline," said Anthem spokeswoman Joyzelle Davis.

According to ACEP, Anthem has a "secret" list, which it will not share, that contains 2000 diagnoses that can be rejected as nonurgent, leaving the patient to foot the bill.

"What they're doing is applying a retrospective analysis," Vidor Friedman, MD, secretary/treasurer of ACEP, said. "They get the diagnosis and then they decide whether it was appropriate for the person to have visited the emergency department," he told Medscape Medical News.

"They're asking their patients to self-diagnose," said Dr Friedman, who is also managing partner at Florida Emergency Physicians in Maitland.

Dr Friedman said that for most individuals, it's not possible to determine whether chest pain, for instance, is due to heartburn, asthma, a pulmonary embolism, or pneumonia. These may all be life-threatening, "but until you do the workup, you don't know what it is," he said.

ACEP also points to data from the Centers for Disease Control and Prevention showing that most ED visits are necessary. The 2014 study of some 141,000 ED visits found that 25% were semi-urgent, 32% were urgent, 7% were emergent, and 0.4% were level 1, necessitating immediate attention. Only 4.3% were nonurgent.

The data "says to me that patients are being reasonably appropriate in their self-triage," said Dr Friedman.

Anthem: Trying to Curb Overuse

Overall, patients may appropriately use emergency care, but if even a few are going for nonurgent conditions, it disproportionately affects other policyholders on the same plan and helps to drive up health costs, said Jay Moore, a senior clinical director for Anthem based in St Louis, Missouri.

The insurer began its review of ED claims when clients — many of them self-insured, with Anthem as the administrator — began complaining about the rising cost of emergency visits, Moore told Medscape Medical News.

Moore said Anthem has not broadly shared its diagnoses list because then it could not be changed quickly, and it is also considered proprietary, he said. When the company decided to institute the policy in Missouri, it shared the list with the state insurance department, which approved the plan, said Moore. It also shared the diagnoses that would be reviewed with the Missouri Hospital Association, local emergency physicians, and ACEP, he said.

According to Moore, no one objected at the time. The same process was repeated in Kentucky and Georgia.

Patients in the states with the policy received letters advising them that ED visits would be subject to review and that if the diagnosis was not considered urgent — upper respiratory tract infection and athlete's foot were two examples given — the patient should use an alternative, such as an urgent care center or Anthem's telehealth program (which requires a $25 copay).

ED claims with the diagnoses are pulled for review by a nurse. If the claim is for a child, it will be paid without further review, said Moore. If it was a Sunday or holiday ED visit, or if the patient lives more than 15 miles from an urgent care center, those claims also are automatically paid. The remainder are then sent to a physician, who reviews the final diagnosis and any other information, including comorbid conditions, said Moore.

ACEP said that some of the diagnoses on Anthem's list would violate the prudent layperson standard, such as "chest pain on breathing." While that diagnosis was on the original list, it has since been removed, said Moore.

If a patient presents with chest pain that later turns out to be gastroesophageal reflux, Anthem will pay that claim, he said.

"I am absolutely certain we are not violating the prudent layperson standard," Moore said.

Insurance Is for Emergencies

The Anthem policy flies in the face of the general philosophy of insurance, said Dr Friedman. "You buy insurance to cover emergencies," he said.

People go to the ED to seek care for a complaint or illness that is an unknown to them, said Dr Friedman. If they are vomiting, they don't know if it's a bowel obstruction or appendicitis. "We believe insurance should cover you under those circumstances, even if the diagnosis turns out to be something that isn't life-threatening."

No evidence supports the idea that the Anthem policy is preventing people from going to the ED, said Moore. Americans are delaying all types of healthcare because of rising out-of-pocket costs, he said.

Even Anthem knows that raising copays for ED visits as a deterrent is "going to have diminishing returns at some point," Moore said. He claims that the insurer's reviews are a more effective way to keep a lid on both inappropriate use and rising healthcare costs.

The survey was conducted by Morning Consult with 2201 adults as a national tracking poll on September 5-8, 2017, on behalf of ACEP. The margin of error is ± 2%.

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