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.