The health plan denies payment if a patient goes to an emergency department and the diagnosis is not a true emergency.
Patients' lives are at risk with Anthem's policy denying coverage for emergency department visits that turn out to be something other than a real emergency, and it is only a matter of time before someone dies as a result of the policy, a leading emergency department physician says.
Anthem BlueCross BlueShield is only likely to abolish the rule after the death of a patient who was afraid to go to the ER for fear of being saddled with paying the entire bill out of pocket, says Ryan Stanton, MD, an emergency medicine physician and CEO of Everyday Medicine in Lexington, Kentucky.
Stanton also works with the American College of Emergency Physicians (ACEP) to educate the public and the healthcare industry on emergency medicine.
Certain death?
Stanton says that death is inevitable.
"They're not going to change it until somebody dies and they get sued. That is going to happen at some point," Stanton says.
ACEP has opposed Anthem's policy since it was first introduced in some states in 2017, calling it a clear violation of the national prudent layperson standard, which requires that insurance coverage be based on a patient's symptoms rather than the final diagnosis.
It also prohibits insurance companies from requiring patients to seek prior authorization before seeking emergency care.
The prudent layperson standard is more than just a good idea. It is codified in the Patient Protection and Affordable Care Act and specific laws in in 30 states.
Answers sought
ACEP recently launched a new video explaining how Anthem's policy hurts patients. In a letter, Sen. Claire McCaskill (D-MO) has asked Anthem's CEO to provide answers and access to internal documents that would help consumers and healthcare providers better understand how the health plan applies the policy.
Anthem has declined to release its list of which diagnoses it will not pay for in the ER. There apparently has been no response to the senator's request, and Anthem declined to comment for this article.
"Patients are not physicians," said Sen. McCaskill in the letter. "I'm concerned that Anthem is requiring its patients to act as medical professionals when they are experiencing urgent medical events."
Anthem has said in the past that the rule would only apply in egregious cases, when a patient incurs ER expenses for an issue that is clearly not an emergency, but Stanton says emergency physicians are seeing examples of how that is not true.
Determining what counts as an emergency
"Anthem continues saying it's about hangnails and the common cold, but I have personally talked to three people who were denied coverage for symptoms that could have been something much more serious. Two were for belly pain and one was a person with a headache so bad they thought they were having a stroke," Stanton says. "These are not all the kind of cases that they're trying to play off as the PR reason for doing it."
One of those patients was a young woman who went to an ER thinking her appendix had ruptured, accompanied by her mother whose appendix ruptured at about the same age. The younger woman had nausea, right lower quadrant pain, and vomiting that the mother said was just like her symptoms. When the cause turned out not to be appendicitis, Anthem denied coverage for the ED visit, Stanton says.
Related: ACEP, Anthem Squabble Over 'Secret' Diagnoses List
"She told me afterward that she would never go to an ER again. She said, ‘You'll have to drag me to the ED on my death bed because I'm afraid of these types of prices and them denying the charges,' " he recalls. "That's what I'm afraid is going to happen more and more. Anthem gets to deny coverage and scare all their customers away from the ER, which will eventually result in bad things."
Right lower quadrant abdominal pain with fever, nausea, and vomiting, will be appendicitis about 5%–10% of the time, he notes.
"With numbers like that, it's only going to take [X] number of patients before someone dies as a result of this Anthem policy," Stanton says. "That's just simple math and a matter of time."
Claim denials
In Kentucky alone, Anthem has denied over one thousand claims in the past seven months, Stanton says.
Some Kentucky hospitals are reporting several hundred denials, and some can't even quantify them because their reimbursement systems are not set up to capture bills denied for this reason, Stanton says. They just write off the loss.
Anthem BCBS has implemented the policy in Georgia, Kentucky, Indiana, Missouri, New Hampshire, and Ohio. Stanton worries that the policy could be applied in more states and by additional health insurance companies.
"This is a policy that they're not going to change as long as they're sitting on the stacks of money it brings in," Stanton says.
Gregory A. Freeman is a contributing writer for HealthLeaders.