Anthem stops covering non-emergency medical conditions treated in the ER in three states

Anthem is no longer paying for non-emergency medical conditions treated in the emergency room in three states. The policy was rolled out in Georgia and Missouri this summer and has been in place in Kentucky since 2015, according to Anthem.

In Ohio, a small group of administrative service organization, or self-funded employers, have also implemented the program.  Anthem said it is still evaluating how this program will be implemented in that state.

"We're evaluating bringing this to other markets but haven't announced any decisions yet," said Anthem spokeswoman Joyzelle Davis.

[Also: New Anthem policy cuts hospital outpatient payment for MRIs, CT scans in 5 states]

The policy applies only to non-emergency care, Anthem said. For non-emergency medical conditions, a primary care doctor is generally the most appropriate provider.

"The primary focus of this program is to promote appropriate care settings for members when they have a non-emergency medical condition," Anthem said in a statement. "It's about getting our members the right care at the right time. If a member feels he or she has an emergency, they should always call 911 or go to the emergency room."

[Also: Only 3.3% of emergency room visits are 'avoidable,' study says]

The problem, according to the American College of Emergency Physicians, which objects to Anthem's policy, is that members and doctors don't always know when a medical condition is a real emergency until after the patient is seen.

One condition on Anthem's non-emergency list is unspecified chest pain, said Vidor Friedman, MD, secretary and treasurer for the American College of Emergency Physicians. A patient with chest pain comes to the emergency room not knowing whether it is heartburn, heart attack or stroke.

[Also: Anthem leaves ACA in Maine amid marketplace volatility]

But according to Anthem, having chest pain when you take a breath does not constitute an emergency, Friedman said.

Chances are, if the patient called his or her doctor's office complaining of chest pain, the physician would recommend an ER visit anyway, Friedman said.

Anthem said it would cover non-emergency ER visits if a member was directed to the emergency room by another medical provider.

Other Anthem exceptions are if the services are provided to a child under 14 years old if there is no urgent care or retail clinic within 15 miles, or if the visit occurs from 8 p.m. Saturday through 8 a.m. Monday or major holiday.

"It's the concept," Friedman said. "If you wake up and got a roach in your ear, is that an emergency? It's not an emergency for Anthem."

Anthem has a list of more than 1,900 ICD-10 codes that will no longer be covered if treated in an emergency room setting, according to ACEP.

"Foreign body in ear" is on the list, he said.

The list includes medical conditions such as abrasion of ear or lip, acne, acute bronchitis, first degree burns of wrist or fingers, chest pain on breathing, cough, influenza, sprains and head abrasion.

Another condition on the list is having a pain in a leg.

If a patient gets off an overseas flight with leg pain, the person doesn't know whether it's venous thrombosis, a serious condition of a blood clot that starts in a vein, or simply a muscle cramp. This can't be diagnosed without an ultrasound, Friedman said.

When it comes to payment, he said, "The insurance company looks at the final diagnosis, after we know the answer." 

He believes this is in violation of the Affordable Care Act's prudent layperson standard, which requires health insurers to cover emergency care based on a patient's symptoms instead of the final diagnosis. For example, ACEP said, a patient with a severe headache and vision problems who is worried about a possible stroke but winds up being diagnosed with a migraine would be covered for a trip to the emergency room under the law.

"Our concern is patients will self-diagnose and delay seeking care, and end up sicker," said Friedman, who works at Florida Hospital Celebration Health in Orlando.

A new poll from Morning Consult, conducted on behalf of the American College of Emergency Physicians, found that more than four in 10 people interviewed, or 43 percent, reported delaying or avoiding emergency care in the past two years out of concern about the cost of copays, coinsurance and deductibles. Nearly half said their medical conditions worsened as a result.

Friedman said he expects patients would be responsible for the bill should Anthem deny a claim. The average emergency department bill is less than $500, he said. This does not include a hospital's facility fee.

"It creates a problem for us as far as receiving payment," Friedman said. "We see ourselves as patient advocates. We feel very strongly that patients make pretty good choices whether to go to the emergency department. There's this myth out there, …. that there's lots of inappropriate use of the emergency department. It's not true."

Only 3.3 percent of all visits to emergency departments are avoidable, according to a study published in August in the International Journal for Quality in Health Care, according to information provided by ACEP.

"Health insurance companies are scaring people away from emergency departments, saying they will decide after the fact what is a real emergency," said Rebecca Parker, MD, president of the American College of Emergency Physicians. "If your insurer disagrees with your decision to visit the ER, they may now refuse to pay. These new actions violate federal law and are dangerous, because people with identical symptoms -- such as abdominal or chest pains -- may either have a deadly medical condition or a non-urgent issue. It is not fair for health insurers to expect patients to know the difference between a heart attack and something that is not life threatening."

A 2013 study in the Journal of the American Medical Association found that there was about a 90-percent overlap in symptoms between emergencies and non-emergencies, ACEP said. 

"Ultimately what we'd like to see, is that the American public will tell Anthem 'No, this is inappropriate,'" Friedman said.

"If a member chooses to receive care for non-emergency ailments at the ER when a more appropriate setting is available, their claim will be reviewed using the prudent layperson standard and potentially denied," Anthem said. "This review is conducted by an Anthem medical director, who takes into consideration the presenting symptoms that brought the member to the emergency room as well as the diagnosis. In reviewing the claim, the medical director considers the member's presenting symptoms that may have appeared to be an emergency even if the diagnosis turned out to be a non-emergency ailment."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com