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Studies Rebut Anthem's Retrospective ED Denials

Shaw, Gina

doi: 10.1097/01.EEM.0000553471.27233.93
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Ms. Shaw is a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work at www.writergina.com.

Brittany Cloyd sought emergency care about a year ago at Frankfort Regional Medical Center in Kentucky for increasing right-side pain and a worsening fever that she feared was appendicitis. Emergency physicians diagnosed ovarian cysts after a CT scan and ultrasound, gave her pain medication, and referred her to a gynecologist.

A few weeks later, Ms. Cloyd received notice from her health insurance provider, Anthem Blue Cross Blue Shield, that she had to pay the entire $12,596 ED bill out of pocket; they had denied coverage of her visit as nonemergent, according to an article on Vox. (http://bit.ly/2P4p72g.)

The policy, first rolled out in Kentucky, Georgia, and Missouri between 2015 and 2017, states that the insurer will deny coverage for visits it deems unnecessary based on a prespecified list of nonemergent conditions. Information that Anthem provided to U.S. Sen. Claire McCaskill showed it had denied 12,200 ED claims in those three states from July 2017 through December 2017, representing approximately 5.8 percent of total ED claims submitted. Anthem has since expanded the policy to include Indiana, Ohio, and New Hampshire.

As many as one in six adults could be denied coverage for ED visits if Anthem's policy were adopted by other insurers, according to new research. (JAMA Netw Open 2018;1[6]:e183731; http://bit.ly/2TTb6If.) The study also found that these denials would not effectively identify unnecessary ED visits.

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Denials Denied

The group, led by Shih-Chuan Chou, MD, MPH, a fellow in health policy research in Brigham and Women's Hospital Department of Emergency Medicine, applied one of Anthem's nonemergent diagnoses to a nationally representative sample of ED visits from Jan. 1, 2011, to Dec. 31, 2015, using the National Hospital Ambulatory Medical Care Survey. The investigators found 15.7 percent of commercially insured adult ED visits had denial diagnoses, and would have potentially been denied coverage under Anthem's policy. The authors also found that nearly 40 percent of visits with nonemergent diagnoses that could be denied coverage based on the Anthem policy had received substantial ED care, including being triaged as urgent or emergent and receiving multiple diagnostic tests.

Some states, such as Kentucky, have enacted similar policies in their Medicaid programs, penalizing members for ED visits later deemed a “misuse.” But these are small amounts, usually around $5-$8, said Dr. Chou. “It's not good, but at least the penalty isn't terribly burdensome,” he said. “But when Anthem started doing this, we began to see reports of people getting thousands of dollars in bills, so we wanted to highlight how this would affect people if it went national.”

As it turns out, most of the ED visits initially denied coverage were ultimately covered when the patients appealed, according to the McCaskill report. “Anthem overturned 62 percent of denied [ED] claims in Missouri on appeal from July 2017 to November 2017—with the rate of overturned decisions increasing each month,” said a press release from the senator's office. “Similar results were seen in Georgia and Kentucky as well, showing that many [ED] claims were denied in error—causing families to deal with the stress of potential unforeseen bills and additional paperwork to appeal the denial.”

Brittany Cloyd's second appeal of Anthem's denial was granted a week after Vox contacted the company to request comment. But she told Vox that the experience left her wary of using the ED again.

EPs know from clinical experience that a patient's reason for visiting the ED can appear serious even when the diagnosis may seem less so. “Someone can come in with chest pain, and after the physician takes a history, does a physical, and perhaps does testing, the ultimate diagnosis is gastritis,” said Jeremiah Schuur, MD, the chief of emergency medicine at the Warren Alpert Medical School of Brown University and the physician-in-chief for emergency medicine at Lifespan Health System. “That's not a life-threatening condition obviously, and if you knew ahead of time that's what you had, you wouldn't necessarily go to the ED. But patients don't have that perfect information.”

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The Past is the Present

It was a wave of similar denial policies under managed care in the 1980s, in which utilization managers reviewed charts and determined that certain visits were unnecessary, that led to the first prudent layperson laws, which require insurance coverage to be based on presenting symptoms, not final diagnosis. These laws, in place in more than 30 states, note that anyone who seeks ED care with apparent emergency symptoms should not be denied coverage if the diagnosis does not turn out to be an emergency. They also prohibit insurance companies from requiring prior authorization before emergency care.

Anthem said in public statements it reviews denials to determine if they are consistent with the prudent layperson standard, but Dr. Chou said that doesn't fly. “When you're trying to make these determinations after the fact, there's no way you can avoid the bias of having retrospective information,” he said.

Anthem may not be alone for long. Harvard Pilgrim Healthcare announced a new policy for emergency coverage to begin Jan. 1. Claims would not be denied for ED visits retrospectively classified nonemergent, as they are under the Anthem policy, but “plan members treated at an ER for nonemergent conditions are responsible for the deductible and 50% coinsurance after the deductible has been met.” (http://bit.ly/2Q0Eiio.)

Harvard Pilgrim noted that the cost-sharing structure applies to nonemergent diagnoses billed in the primary position, with the most common examples being respiratory infections, sprains and strains, superficial injuries, contusions, ear conditions, and physical exams.

“We understand that insurers are under pressure to control costs, and are trying all sorts of different things,” Dr. Schuur said. “But our concern is that these policies will not be accurate, and will force patients to be their own doctors in order to determine if whatever symptom they have will be worthy of health insurance coverage.”

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