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At ABCS RCM, we routinely report on major legal actions which may have an impact on the healthcare provider and revenue cycle management industry. One such major legal action related to the healthcare industry is working its way through the American legal system. The outcome could directly influence the way insurance providers reimburse medical claims as well as what is considered appropriate patient care.
A new strategy for controlling healthcare cost is being implemented by one of the largest health plans in the United States. Anthem Blue Cross Blue Shield (BCBS) provides health insurance for more than 40 million members. The insurance company has started asking its members to play a larger role in diagnosing their own medical conditions.
In order to accomplish this, Anthem has been denying submitted emergency room (ER) claims if the medical procedure is deemed inappropriate. By inappropriate, Anthem argues that the medical condition which was treated — was not a true emergency.
Anthem has not provided specific guidelines as to what is considered an appropriate visit to an emergency room. But, the insurance provider has stated that it does not want individuals insured by its policies automatically go to an ER for medical treatment. Members should decide whether they just as easily could receive treatment at a doctor’s office, urgent care or retail health clinic.
The health insurance provider states that more than a quarter of its plan members’ emergency room visits were not necessary. Anthem states that unneeded ER visits cost the healthcare system $4.4 billion a year. Specifically for Anthem, the cost is over a one billion dollars per year.
Anthem’s new emergency room policy is expanding across many of the Southern and Midwest states.
Critics point out that these denied claims are made after the patient visits the ER. The fear is that the denial is based on the diagnosis and not the symptoms.
The Doctor-Patient Rights Project (DPRP) argues that Anthem has instituted an organized policy of denial designed to make its members afraid to visit an ER out of fear of receiving an enormous medical billing.
The practice of retroactively denying coverage for emergency room visits based on a patients’ diagnosis and not his or her symptoms, is unacceptable. Anthem is expecting patients to act like a doctor and diagnose themselves when they are potentially facing a life-threatening medical event.
Anthem vs. Physicians
Anger towards Anthems new policy has been building. Several Federal and state lawmakers have explored ways to penalize the health insurance provider. As one Ohio lawmaker bluntly stated, “We don’t buy insurance for the insurance company to be the doctor.”
In Ohio, a new bill was introduced in the state house to prevent Anthem from continuing this practice. House Bill 536 would prohibit selective emergency services insurance coverage. At the time of this article’s publication, the bill was still in committee.
Other lawmakers from Missouri and Maryland have criticized Anthem’s ER policy. They even sent a letter in March to the Health and Human Services Department and Labor Department, asking the agency to investigate the denied ER payments.
In 2018, disagreement over Anthem’s insurance policy of denying payment for emergency department claims escalated into a lawsuit. Two separate healthcare organizations, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG), are suing Anthem
Blue Cross Blue Shield of Georgia.
Both medical groups advocate that Anthem’s ER reimbursement policy is illegal under the standards set by the Affordable Care Act (ACA). They argue that federal law requires insurance providers to cover emergency care based on a patient’s symptoms rather than their final diagnosis.
There is a feeling that healthcare practitioners and patients alike are operating in fear of denied payments for medical claims. Physicians are asking the court to require Anthem to stop its ER policy and pay submitted medical claims.
Doctor’s believe that Anthem’s policy went beyond what is legally allowed for medical reimbursement. The health insurer had reviewed the medical cases of patients who had visited an emergency room, and then decided whether to pay for their care based on billing information or medical records related to the incident.
In following this approach healthcare practitioners feel that Anthem violated legal requirements that insurers cover care in a situation where a “prudent layperson” would believe he or she was experiencing an emergency.
The lawsuit argues that Anthem started this emergency-room billing policy in the states of Georgia, Kentucky
Conflicting Statistical Data:
Part of the difficulty in trying to achieve a meeting of the minds is due to the fact that both parties disagree with what the data. Recent federal data actually displays divergent trends between overall visits and nonurgent visits for Emergency rooms.
According to data from the Centers for Disease Control and Prevention (CDC), hospital ER visits in 2015 declined by 3 percent when compared to 2014.
However, the CDC results conflicted with recent data from the Agency for Healthcare Research and Quality (AHRQ), which found that ER visit rates had reached a 10-year high for all age groups in 2015. AHRQ also found a 3 percent increase in ER usage in 2014.
Most likely, these two federal agencies using different sampling techniques to extrapolate national figures. So it is challenging to construct a baseline of information in order to discover current ER utilization trends.
Response from Ohio Medical Organizations
Ohio Chapter of the American College of Emergency Physicians (Ohio ACEP) and the Ohio Hospital Association have both expressed concerns about Anthem’s ER billing policy. They have also both communicated their concerns directly with Anthem as well as the Ohio Department of Insurance.
Other medical organizations like The Ohio State Medical Association (OSMA) also question the Anthem’s emergency room billing policy.
The goal of Anthem BCBS is to reduce the cost of ER treatments. By its very nature, seeking treatment in a hospital’s emergency department is more expensive. Especially when compared to similar treatments when there are administered in a physician’s office or walk-in medical clinic. And yet, there is still disagreement as to the cost and utilization of emergency rooms by patients.
Opponents of Anthem’s new ER policy argue that the insurance provider is controlling expenses in a way that is actually illegal and could harm patients. Having insurance members self-diagnosis as to whether their symptoms require a visit to an ER for treatment is beyond the scope of the average patient. A long-term potential outcome is that patients will start to skip medical treatments out of fear of generating large healthcare bills.
At ABCS RCM, we will continue to follow this case. Similar to recent major lawsuits against United Healthcare and opioid drug manufacturers, many healthcare industry observers are also watching how the courts rule on this medical billing topic. Whatever the final ruling, the outcome will influence how medical claims are processed (and denied) by large insurance providers.
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Emergency Room Billing Policies, Anthem Insurance