Retroactive denial policies for emergency room care, such as the one Anthem rolled out in several states, place a financial burden on patients and prevent them from seeking care, according to a Doctor-Patient Rights Project study.
Here are seven things to know:
1. The study found many patients’ claims for ER care are denied retroactively because the insurer deems the visit “avoidable.” The report specifically addresses Anthem Blue Cross Blue Shield’s retroactive denial policy.
2. Anthem denied more than 12,000 emergency care claims from patients in Missouri, Georgia and Kentucky in the second half of 2017 on the grounds they were “avoidable.” The denials reflected about 5.8 percent of total ER claims submitted in the three states during this period. However, when patients challenged the denials, Anthem proceeded to reverse itself and pay the claims most of the time.
3. Under Anthem’s policy, it may deny claims for ER visits it has deemed unwarranted or nonemergent. However, there are several exceptions to the policy, including ER visits for policyholders under age 14 and patients with physician referrals to the ER. Data from the American College of Emergency Room Physicians provided to The New York Times suggest denials plummeted to nearly zero after the exceptions were added.
4. Emergency care denials leave patients with medical debt that can deter them from seeking care for other health issues, according to the Doctor-Patient Rights Project. The report cited a 2016 Kaiser Family Foundation survey that found 31 percent of households with medical debt failed to properly treat other health problems as a result. The KFF survey also found that families with medical debt are up to three times more likely to delay or skip healthcare than families without medical debt.
5. “By retroactively denying coverage for emergency visits based on a patient’s diagnosis and not his or her symptoms, insurers are expecting patients to play doctor and diagnose themselves when they’re potentially facing a life-threatening medical event,” Vidor Friedman, MD, president of the American College of Emergency Physicians, said in a press release.
6. Dr. Friedman argues the retroactive denial policies violate the “prudent layperson standard,” which is part of federal law and requires insurers to cover patients who have symptoms suggestive of an emergency.
7. Anthem continues to stand behind its controversial policy. In a statement to The New York Times in July, Anthem said it remains committed to its avoidable ER policy “because the costs of treating nonemergency ailments in the ER has an impact on the cost of healthcare for consumers, employers and the healthcare system as a whole. Anthem has made, and will continue to make, enhancements to ensure consumers are receiving the right care at the right place and time.”
Date: December 6, 2018