Editorial: At Anthem, rules for ER visits changing

Wednesday, May 23, 2018

There it was, near the end of a long Sunday New York Times story about insurance giant Anthem’s new policy of denying payment for emergency room visits it deemed unnecessary. The policy, first put in place in Georgia, Indiana, Missouri and Kentucky, was soon to be instituted in New Hampshire. It is a policy that insurance regulators, legislators, physicians and Anthem members –including state employees and their families – should monitor and question.

In states where the policy has been in place, people who misdiagnosed themselves received big bills. In Kentucky, a woman thought she had appendicitis because of the pain and its location, so she sought treatment in an emergency room. Appendicitis can be fatal, but her lower abdominal pain turned out to be caused by ovarian cysts, which Anthem initially ruled did not qualify for emergency treatment. She got a bill for $12,000.

In the Times story, a man who thought he had slipped a disk because the pain brought him to his knees went to his local ER. It turned out he had sprained his back. He got a bill for $1,722. The stories go on and on. Initially, Anthem based its decision on whether to pay or deny a claim on the diagnosis, not the symptoms that sent the patient to the hospital. It subsequently changed its policy to take symptoms into account. On the second appeal Anthem reversed itself and paid the bill of the woman who thought she had appendicitis.

The company has continued to revise its rules. Its policy in New Hampshire will apply to just 14 medical codes or classifications for types of treatment and care. It will not, for example, pay the ER bill of someone who goes to the hospital for a blood pressure check or a physical exam. Rules like that make sense. The average cost of non-emergency care in an emergency room, Anthem says on its website, is $1,000. Unnecessary visits clog emergency rooms, waste staff time and drive up everyone’s medical bills.

Anthem will pay for emergency room visits, even when it might otherwise deem them inappropriate, when the member was referred by another medical provider, when the services are provided to a child under age 14, when there’s no urgent care facility within 15 miles, and if the visit occurs on a Sunday or major holiday.

Insurers and emergency room physicians disagree dramatically about how much emergency care is unnecessary, but minimizing visits that could be addressed in an urgent care setting or with a call to a nurse or doctor hotline benefits everyone. But how is one to know when chest pain is caused by a heart attack or last night’s pepperoni pizza?

Federal law requires that insurers cover emergency claims if “a prudent layperson” had reason to believe his or her health or life was in danger. On its New Hampshire website, Anthem uses the standard definition of a prudent layperson as someone who “has an average knowledge of health and medicine.” But what does that mean? If such information exists, we were unable to find it.

Insurance company denials of claims should be appealed first to the company and, if not reversed, to New Hampshire’s Insurance Department, which wants to hear about them. The claims are then reviewed by a panel of medical experts convened by the department, whose decision is final.

The American College of Emergency Physicians says that fear of a big bill will keep some people from seeking necessary, perhaps lifesaving, care. If those fears prove to be true, claim denials for ER visits will have to be prohibited. In the meantime, patients are caught in a battle between insurers and physicians, which leaves us with this thought: What a way to run a medical system.