Since early summer, ACEP has been working hard on behalf of its members to protect the prudent layperson standard by advocating for the reversal of a dangerous new policy being enforced by the insurer Anthem BlueCross BlueShield in six states.
First implemented in July in Georgia, Kentucky, and Missouri, and most recently expanded at the start of this year to Indiana, New Hampshire, and Ohio, the policy allows Anthem to retroactively deny coverage of emergency department visits that the insurer deems as “nonemergent.” Anthem uses a list of so-called nonemergent ICD-10 codes to flag emergency department claims for medical review, which is then performed by an Anthem-employed physician medical director. However, unlike the more customary review process, no patient chart is requested; the medical director simply reviews the claims form and the limited information it contains on the encounter to make a determination on whether to deny.
As a result, there have been denials that include a pedestrian struck by a vehicle who was taken to the emergency department by EMS (final diagnosis after CT scan and X-rays: contusions and abrasions) and an emergency department patient presenting with severe abdominal pain with fever (final diagnosis: ruptured ovarian cyst). Following a denial, patients are left holding a bill for the entirety of their emergency department visit, which they are now responsible for paying on their own.
In response, ACEP has engaged in a multipronged advocacy strategy, employing a range of tactics and building partnerships with key allies along the way. ACEP has worked closely with chapters in the affected states that have been able to very effectively leverage their local ties with policymakers, coalition partners, and the media. State legislation that includes provisions to counter Anthem’s strategy has been introduced in Georgia, Missouri, and Ohio.
In Washington, D.C., ACEP has repeatedly met with key congressional offices for each of the six states to inform them of the policy and provide educational materials to counter Anthem’s claims; chapters are working similarly in the district offices for these members of Congress. As a result, in late December, Sen. Claire McCaskill (D-MO) sent Anthem a letter requesting the insurer provide her office with all internal documents and emails leading to the policy’s implementation. Noting that “patients are not physicians,” the letter reiterated the prudent layperson standard and requested that Anthem explain how the emergency denials policy is not in violation of it. In addition, the senator has asked for communications including discussions about the potential cost savings related to this policy and any associated complaints it may have received.