ER doctors: Anthem policy to deny coverage for some visits is dangerous

May 06--A group of emergency room doctors is pushing back on a program from Anthem Blue Cross and Blue Shield that could deny reimbursement for those using the hospital emergency room for treatment the insurer doesn't deem an emergency.

Emergency room physicians say the policy ultimately could lead to higher health-care costs or even lost lives.

But the Indianapolis-based insurance company said treatment in a hospital emergency room is considerably more expensive and time-consuming than if a patient had gone to an urgent care or walk-in clinic.

In an attempt to contain healthcare costs, it began testing a program -- that began rolling out in Georgia, Missouri and Kentucky in 2015 and was extended Jan. 1 to include Indiana, Ohio and New Hampshire -- that could deny reimbursement for emergency room visits the insurer deems unnecessary.

The program applies to those with an Anthem plan provided from an Indiana employer or a policy that was purchased on the individual market. Anthem would not reveal how many customers it has, but the company indicated it is the largest health plan in the state.

"Anthem's avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies as the costs of treating non-emergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the health care system as a whole," Anthem spokesman Tony Felts said via email.

But the change has caused a backlash of criticism and stories of people who went to the emergency room because they thought they were suffering from a serious issues, but ended up with significant medical bills because their conditions were deemed to be non-emergency matters.

The American College of Emergency Physicians has fought back against the policy by issuing press releases and videos highlighting the dangers in the program. Beacon Health System declined to comment on the issue, but Saint Joseph Health System indicated it has taken action to build awareness about the change with signage and handouts throughout its physician network locations.

"Unfortunately, patients impacted by policies like these are sometimes unclear about what the policy means as far as the way they receive or seek medical care," Saint Joseph spokeswoman Jessica Schramski said in a statement. "These policies often encourage patients, without any medical training, to make decisions about what constitutes an emergency. ..."

We urge patients to always seek medical care immediately if they feel they are experiencing an emergency."

Dr. Gina Huhnke, immediate past president of the Indiana chapter of the College of Emergency Physicians, said it seems as if Anthem is using Indiana and the other states as a testing ground for a practice that will likely keep expanding or be adopted by additional insurance companies.

Non-emergency use of emergency rooms isn't nearly as widespread as Anthem suggests, with only about 5.5 percent of the ER visits labeled as non-urgent based on figures from the Centers for Disease Control, she said. Conversely, 94.5 percent of ER visits are therefore real emergencies, she added.

"The problem with the policy is that it puts people in the position of trying to make a diagnosis before deciding where to go," said Huhnke, who is an emergency room physician in Evansville, Ind. Chest and abdominal pain are common reasons for a person to visit the emergency room, she explained.

And if someone with a significant problem goes to a walk-in clinic or ignores the problem altogether, the situation could get a lot worse, resulting in even higher medical expenses for the insurance company, she explained.

"My biggest concern is a patient who won't seek care when they need it because they are worried about the bill," she said. "A person with no medical knowledge cannot be expected to make an accurate diagnosis before deciding where they should go."

And it's unfair for Anthem for saddle patients with the bill if they made the wrong diagnosis or didn't have the ability to get to a walk-in clinic, she said.

The emergency physicians said health plans must provide fair payment for emergency services or patients will suffer. It said the public should contact legislators and others to fight back.

But Anthem already has and will continue to make changes to the program to ensure it is effective and fair, Felts said, adding that it has "expanded the list of always-pay exceptions."

"If a consumer chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, an Anthem medical director will review the claim information and medical records using the prudent layperson standard. In the event a member's claim is denied, they have the right to appeal," he explained.

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