ACEP, Anthem Squabble Over 'Secret' Diagnoses List

John Commins, October 11, 2017

Moore says Anthem has responded to ACEP’s concerns about some of the diagnoses on the list.

"ACEP got our list and it was an early copy and it has 'chest pain on breathing.' They called us and said 'did you know chest pain on breathing is on the list?' We said, 'Hey, you are right!' so we took it off the list. It is no longer on the list of screening diagnoses," Moore says. "They continue to cite that even though they know it is off the list."

Moore says the screening list is one of a number of strategies that Anthem has developed to encourage patients to access care in less-expensive venues. Those strategies include bolstering the primary care and urgent care networks, and expanding telemedicine services.

Patients are usually notified that their claim has been denied several weeks after the ED care has been administered.

"They won’t find out in the ER," Moore says. "That would require the ER to call in the information and they would be doing a pre-certification for the ER visit and we don’t want to put that administrative burden on the ER. It will slow down the ER and reduce its mission to quickly respond."

He says patients can appeal the denial of coverage, and are told before they sign up for coverage that emergency department care is only covered for emergencies.

"You can’t have it as a primary care doctor. It’s not efficient. It’s not cost-effective, and it costs everyone else on the plan a lot of money," he says. "This is not going to affect the great majority of people. This is only going to affect a small number of claims and a smaller number of patients because it tends to be the same patients who abuse the system again and again."

John Commins

John Commins is a senior editor at HealthLeaders Media.

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