A collection of seven national associations representing hospitals, medical schools and health systems sent a joint letter March 5 to Anthem Blue Cross and Blue Shield (Anthem) opposing two policies affecting “non-emergency” care administered in the emergency department (ED) and advanced imaging services provided in hospital outpatient departments. The American College of Radiology (ACR) commends prominent organizations such as the American Hospital Association (AHA), Federation of American Hospitals (FAH), and Association of American Medical Colleges (AAMC) banding together to urge Anthem to rescind these harmful coverage and site-of-service policies.
This letter marks the second time in as many weeks that various hospital stakeholders publicly raised concerns that Anthem’s ED avoidance and advanced imaging site-of-service guidelines are detrimental to patients. The hospital associations are particularly concerned that Anthem is reducing patient access to key life-saving services and dictating where individuals are permitted to receive care solely based on cost, rather than quality. The hospital stakeholders also questioned Anthem’s commitment to implementing these reimbursement policies in a transparent manner.
With respect to retrospective denials for “non-emergent” services administered in the ED, Anthem appears to be relying solely on final diagnosis codes, rather than a patient’s symptoms upon initial arrival at the hospital. The hospitals argue that the insurer’s decision to ignore patients' individual clinical circumstances when they are first admitted to the ED is a violation of the federal Prudent Layperson Standard. 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.
The letter also highlights hospitals’ ongoing concern with Anthem’s reliance on implementing the hospital outpatient department advanced imaging policy via a utilization management and site-of-service algorithm developed by AIM Specialty Health, a for-profit radiology benefit management company. These proprietary software algorithms are typically not made available for patient or physician review,despite their profound impact on access to care.
The combined efforts of the ACR and the American College of Emergency Physicians (ACEP), in coordination with numerous hospital organizations such as AHA and FAH, contributed to Anthem amending both the ED avoidance and advanced imaging site-of-service denial policies. The College appreciates these policy improvements, but will continue working with Anthem until cost considerations are not their primary focus on coverage decisions. ACR members should continue to consult Advocacy in Action eNews for additional information on Anthem’s coverage and reimbursement policies.