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ACEP, Anthem Squabble Over 'Secret' Diagnoses List

News  |  By John Commins  
   October 11, 2017

Anthem says its list is an in-house screening tool to identify non-emergent care in the ER, but emergency physicians say it's a violation of the prudent layperson standard and could harm patients.

Emergency physicians say Anthem Blue Cross Blue Shield has created a "secret list" that contains about 2,000 emergency department diagnoses that the insurer will not pay for.

"There are things on there like 'chest pain with deep breaths' which we know as clinicians could be pleurisy but it could be a pulmonary embolism or a collapsed lung or influenza," says American College of Emergency Physicians President Rebecca Parker, MD.

"Thousands of people die from influenza every year," she says. "It’s like looking for a needle in a haystack and patients shouldn’t have to figure out whether or not they have an emergency."

Parker says ACEP learned about Anthem’s list from its state chapters in Kentucky, Georgia and Missouri.

"Anthem has to abandon this policy. It is bad patient care. It is not the way to look at appropriate use of acute care services," Parker says, adding that Anthem’s diagnoses list violates the prudent layperson standard — which is in the Affordable Care Act and in many state laws.

Instead of denying ED claims, Parker says Anthem should improve its provider network and expanding access points for care beyond the emergency department.

"Patients need to know that their insurance will cover them when they have emergency symptoms. We don’t want patients trying to make that decision at home," she says. "I don’t want someone clutching their chest wondering if they are going to be covered by their insurance company. People will die."

Anthem Responds

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. 

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 is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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