The American College of Radiology (ACR) is pleased that Anthem Blue Cross Blue Shield’s (Anthem) policy of denying beneficiaries’ coverage for “non-emergent” services administered in the emergency department (ED) now includes exceptions for lifesaving advanced diagnostic imaging services, retrospective to January 1, 2018.
Developing policies that successfully encourage patients to seek treatment for routine clinical conditions outside of the ED remains a key concern for all health insurance companies. Insurers regularly cite lowering the rate of “unnecessary” ED visits as a crucial method for controlling ever-escalating health care costs.
In August 2015, Anthem enacted an aggressive ED avoidance policy that permits the insurer to retrospectively review all beneficiary visits to the ED in Kentucky. If these post-service reviews indicate patients received treatment for non-emergent conditions, Anthem denies the claim and requires the patient or the patient’s family to pay the cost of ED care. Anthem enacted similar policies in Missouri and Georgia in June and July 2017, respectively. By January 1, 2018, the ED policy became effective in Ohio, Indiana and New Hampshire, as well.
The ACR, in concert with the American College of Emergency Physicians (ACEP) and American Hospital Association (AHA), disputed the cost-controlling benefits of this policy and demonstrated that Anthem’s ED avoidance policy threatens patient access to important clinical care. This stakeholder group also argued that Anthem’s actions likely ran afoul of federal law, specifically the Prudent Layperson Standard. It mandates insurance coverage in the ED based on an individual’s symptoms, not their final diagnosis. Under this standard, a person with average knowledge of health and medicine that reasonably expects the absence of immediate medical attention to result in serious health care problems should not face any barriers to ED treatment.
Combined pressure from the ACR, ACEP and AHA helped prompt Anthem to announce the creation of additional “always pay” exceptions to the flawed ED policy in mid-February 2018. According to numerous published media reports, these exceptions include:
- Provider and ambulance referrals
- Services delivered to patients under the age of 15
- Visits associated with an outpatient or inpatient admission
- ED visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles way
- Visits occurring between 8 a.m. Saturday and 8 a.m. Monday and
- Any visit where the patient receives surgery, intravenous (IV) fluids, or medications, or an MRI or CT scan
In a recent letter, Senators Claire McCaskill (D-MO) and Ben Cardin (D-MD) pressed Secretary of Health and Human Services Alex Azar to examine the response of his agency and the Department of Labor to potential violations of the federal Prudent Layperson Standard. The letter cited these same services or care scenarios as exempt from the Anthem ED review policy.
The ACR continues to request a formal, written copy of the “always pay” exceptions from Anthem, but it has yet to provide this communication.
While we continue to oppose the underlying Anthem ED avoidance policy, the ACR is pleased that patients will no longer be subjected to this flawed concept if they receive advanced imaging procedures. ACR members should continue to consult Advocacy in Action e-News for additional information on Anthem’s ED and site-of-service denial policies.