ACEP, Anthem Squabble Over 'Secret' Diagnoses List

John Commins, October 11, 2017

Anthem Responds

Jay Moore, MD
Jay Moore, MD

Jay Moore, MD, a senior clinical officer at Anthem, says ACEP is mischaracterizing how diagnoses screening lists are used. He says about 95% of all ED diagnoses codes Anthem processes are approved automatically without review, and that only "5% or less, depending on the market" trigger a flag.

"There is no 'secret black list code' that you are automatically not covered and we aren’t going to pay for a diagnosis," Moore says. "We told ACEP several times but I think they are marketing it this way because they don’t like the policy in general."

"It’s a screening list of diagnosis code that flag that case for review," he says. "It is designed to get on top of a trend that we have seen for some time in emergency rooms. We are seeing more and more people across all payers showing up who have less-than-emergent conditions. I’m talking about things like literally athlete’s foot or a headache, and I don’t mean a migraine; things we wouldn’t consider emergencies."

In the rare occurrences when a diagnosis is flagged, Moore says, it starts a review process that considers mitigating factors.

"A nurse starts by looking at the case and they make a determination as to whether the person is a child, or if it was a weekend or holiday where an urgent care might not be open" he says. "The other check is how close a person lives to urgent care, because you could go there instead of an emergency room."

"If someone lives in the country they may not have good Internet or many healthcare providers and the emergency room might be their best option, even for something that is relatively minor. We approve those cases regardless of the diagnosis," he says.

"If none of those exceptions are met the case is forwarded to a board-certified physician. They look at all the information the hospital sends us on a claim, including the diagnoses codes," Moore says.

"If you come in with some redness on skin that you think is an infection, but the final diagnosis will be poison ivy, that would show up on our screening list," he says. "But then we see the initial diagnosis and that would tell us why that person went to the ER. That is reasonable for someone with that condition."

Moore says the list of flagged diagnoses will not be made public "because we are refining our data and we are trying to decide what codes should and should not be on the list."

"We don’t want there to be some kind of master list that we have to keep updated and provide provider notification, and since it is just a screening list we aren’t obligated to share it," he says. 

John Commins

John Commins is a senior editor at HealthLeaders Media.

Facebook icon
LinkedIn icon
Twitter icon