Senator Claire McCaskill, D-MO, is going after insurer Anthem on its policy to deny payment for emergency room treatments thatare later determined not to have been an emergency.

|

Modern Healthcare reportsthat according to Anthem, it changed its policy in Georgia andMissouri this past June, while it claims to have begun putting thepolicy in place in Kentucky as far back as 2015. However, that’s indispute by some medical personnel in Kentucky.

|

“We had no evidence that any claim was refused until about threeor four months ago,” it quotes Dr. Ryan Stanton, an emergencyphysician in Lexington, Kentucky, and a spokesman for the AmericanCollege of Emergency Physicians, saying in the report.

|

In fact, Stanton said in the report that over the last fourmonths, Anthem claim denials have been “in the hundreds” byproviders all over the state. He says in the report, “Our concernis that what this policy is going to do is encourage people to waitat home and let something get worse to the point where we can't doanything about it.”

|

Stanton says the problem is Anthem’s method of reviewingemergency department cases, often basing its denial solely ondiagnostic ICD-10 codes instead of medical records. While providerscan appeal, it’s only at that point that Anthem will request toreview the patient’s records. Large providers experience so manydenials that it costs them more to appeal than to simply pass alongthe cost to the patient or chalk it up to uncompensated care, butsmaller hospitals can be put in financial jeopardy by accumulatingso much bad debt.

|

Says Stanton in the report, “If we don’t fight and the patientdoesn’t fight, then Anthem wins. They’re just seeing how many ballsthey can throw and we’re going to watch go by without taking aswing at them. So far they’re doing pretty good.”

|

Stanton also fears patients will self-diagnose for fear Anthemwon’t cover emergency room treatment, saying, “Unfortunately, we’regoing to end up having to send them coroner reports on things thatwere not evaluated because the patient didn’t want to go the ERbecause they assumed Anthem wouldn’t cover it.”

|

According to the report, Anthem has said in the past that itsdecision to implement the policy had to do with increases it hasexperienced in claims for non-emergent ED visits in thosestates.

|

The policy doesn’t affect Anthem’s Medicare patients, onlycommercial plan members.

|

In a letter sent to Anthem’s CEO, McCaskill saidthe policy raised “serious concerns” about whether Anthem was inviolation of state and federal laws that require insurance coveragebe based on a patient’s symptoms, not the final diagnosis.

|

McCaskill has asked for all internal correspondence related toAnthem’s decision to institute its policy, as well as anypresentations to senior corporate management or government entitiesregarding emergency care utilization.

|

Other documents she’s asked for are any complaint Anthem hasreceived from any entity related to its emergency care coverage inGeorgia, Kentucky and Missouri, communications the insurer receivedfrom hospitals about the policy, documentation related to thepotential cost savings expected from the policy change and anydocuments detailing possible exceptions to the policy.

|

Anthem plans to expand the policy to Indiana, New Hampshire andOhio as of January 1.

|

Complete your profile to continue reading and get FREE access to BenefitsPRO, part of your ALM digital membership.

  • Critical BenefitsPRO information including cutting edge post-reform success strategies, access to educational webcasts and videos, resources from industry leaders, and informative Newsletters.
  • Exclusive discounts on ALM, BenefitsPRO magazine and BenefitsPRO.com events
  • Access to other award-winning ALM websites including ThinkAdvisor.com and Law.com
NOT FOR REPRINT

© 2024 ALM Global, LLC, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to [email protected]. For more information visit Asset & Logo Licensing.