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If Anthem's Policy Spreads, 1 in 6 ER Visits Could Be Denied Coverage

Analysis  |  By Alexandra Wilson Pecci  
   October 30, 2018

If the cost savings are there, other insurers will likely follow in Anthem's footsteps.

Nearly one in six emergency department visits by commercially insured adults could be denied coverage if all commercial insurers adopted Anthem's policy to potentially deny coverage of unnecessary ED visits.

That's the scary statistic from a study published last week in JAMA Network Open by researchers at Brigham and Women's Hospital.

But how likely is such as scenario? And what should hospitals and health systems do about it?

"I think [insurers] are thinking, to see how it plays out before they jump on the bandwagon," says Walter Morrissey, MD, managing director of Kaufman Hall.

However, if the cost savings are there, he believes other insurers will likely adopt a policy similar to Anthem's.

Anthem's policy denies coverage and payments for ED visits that it deems unnecessary. If the final ED diagnosis is among a prespecified list of nonemergent conditions, the insurer will review the ED visit and may deny coverage.

So far, the policy has been implemented in six states, but the new JAMA Network Open study shows how prevalent denials could be if the Anthem policy becomes widespread.

Policy spread consequences

The researchers studied ED visits of more than 28,000 commercially insured patients and found that Anthem's list of nonemergent diagnoses would classify coverage denial for 15.7%, or 4.6 million ED visits annually.

In almost 90% of visits, the primary presenting symptoms that brought patients to the ED were the same presenting symptoms as those with diagnoses at risk of denial.

In addition, more than 65% of patients that could be denied coverage received emergency-level services, such as imaging or multiple blood tests, the study showed.

Critics of the policy say that it dangerously puts medical decisions in patient hands.

"The risk is putting a burden on the patient to determine whether their symptoms are serious or not," Morrissey says.

The American College of Emergency Physicians and the Medical Association of Georgia made that argument when they sued Anthem's Blue Cross Blue Shield of Georgia in July, alleging that the policy violates the "prudent layperson" standard in the Affordable Care Act.

The JAMA Network Open study bolsters this point, showing that emergency symptoms overlapped with nonurgent symptoms 87.9% of the time.

Moreover, even "among patients with potentially life-threatening symptoms such as chest pain, who would likely be instructed to seek emergency care if they consulted outpatient clinicians, up to 4% may be denied coverage and possibly receive an uncovered medical bill," the authors write.

And if patients are worried about denials, that there's a risk that those worries will "lead them to skip care or defer care and have a bad outcome," Morrissey says.

The study authors write, "If retrospective denial policies are widely adopted, they would place undue financial stress on patients with acute illness and could increase barriers to timely emergency care, particularly to those least able to pay."

A new reality

For hospitals and health systems that are grappling with the new policy, Morrissey has several pieces of advice.

The first is "understanding what's getting denied, and what's not, and under what circumstances," he says.

Just because a case is eligible for review, doesn't mean Anthem will deny it.

"They're not nearly as doing it as much as they could," Morrissey says.

The study authors point out that "while 10% to 20% of ED visits were reviewed by Anthem for denial, only 4% to 7% of ED visits were ultimately denied."

Plus, there are patients who appear in the ED who clearly should not be treated there, like those with sore throats or who get imaging for a mild ankle sprain.

"It's better for everyone that they not be treated in an ED," Morrissey says.

Next, because Anthem's retroactive coverage denials are based on discharge diagnoses, revenue cycle leaders should work to ensure that there's appropriate and adequate documentation to "help determine whether a visit was appropriate or inappropriate for an ED setting," Morrissey says.

Finally, he says says access and education are important for patients who might view the ED as their only or best option for care.

Although emergency providers shouldn’t be expected to change the way they treat patients, a strong triage process in the ED and providing access to both urgent care and off-hours primary care services are important.

"It comes down to effective access, first and foremost," Morrissey says.

Alexandra Wilson Pecci is an editor for HealthLeaders.

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