Insurers could deny 1 in 6 ER visits if they were to adopt Anthem policy, JAMA says

CALAAEM News Service at
Wed Oct 24 20:43:33 PDT 2018


Oct. 23, 2018

Insurers could deny 1 in 6 ER visits if they were to adopt Anthem policy,
JAMA says


s-if-they-were-adopt-anthem-policy-jama-says> Healthcare Finance News


Susan Morse, Senior Editor


If Anthem's policy of denying what it deems as unnecessary emergency room
visits was universally adopted by other insurers, nearly one in six visits
to the ER by commercially insured adults could be denied coverage, according
to a study released by JAMA, the Journal of the American Medical


The emergency room is the most expensive setting for care. Value-based care
is moving patients away from ER visits when avoidable.


The JAMA study shows health insurers are increasingly adopting policies to
reduce emergency room visits they consider unnecessary.


Last year, Anthem, one of the nation's largest insurers, set policy to deny
coverage if it determined through the discharge diagnosis that the visit was


Anthem said it was striving to make healthcare more affordable.


But physician groups, including the American Medical Association, objected
to the policy. The American College of Emergency Physicians said members,
and even doctors, don't always know when a medical condition is a real
emergency until after the patient is seen.


After getting numerous objections, Anthem amended its policy. As of January
1, the insurer said, it would always pay for ER care if the visit is based
on a referral from a provider or ambulance; it services patients under the
age of 15; the visit is associated with an outpatient or inpatient
admission; the emergency room visit occurs because a patient is either out
of state or the appropriate urgent care clinic is more than 15 miles away;
the visit occurs between 8 a.m. Saturday and 8 a.m. Monday; and when the
patient receives surgery, IV fluids, IV medications, or an MRI or CT scan.


In 2017, Anthem implemented the policy in Georgia, Missouri, and Kentucky,
expanding in 2018 to New Hampshire, Indiana, and Ohio, with expansion to
more states underway.


JAMA set out to determine the impact of Anthem's policy through a sampling
of ER visits by commercially-insured patients ages 15 to 64 between 2011 and


It found that 15.7 percent of commercially insured adult ER visits were
denied based on diagnosis.


Also, the study said, from a patient perspective, the ER visit was
necessary. The most common symptoms prompting a visit were abdominal pain,
chest pain and headache.


Also, in up to nine of 10 visits patients presented the same symptoms
between emergency and non-emergency level care.


However, the study also found that, while 10 to 20 percent of emergency room
visits were reviewed by Anthem for denial, only 4 to 7 percent were
ultimately denied.


Anthem's policy of retroactive coverage denial based on discharge diagnosis
has led to a congressional investigation by Sen Claire McCaskill of Missouri
for potential violation of the prudent layperson standard, JAMA said.


Another recent JAMA study looked at ER use among patients with a mental
health diagnosis. It found that prior patient visits and patient illness
severity associated with a mental health diagnosis could be important
contributors to increased ER use.


The cost-reduction policy could place many patients who reasonably seek ER
care at risk of coverage denial, the study said.


The policy cannot accurately identify unnecessary visits, as up to 40
percent of the visits that were considered non-emergency were likely
appropriate ER visits. 


The assumption underlying Anthem's policy is that patients should be able to
determine whether their symptoms warrant emergency care.



Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service


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