Anthem sued by doc groups over ED policy

Anthem has implemented the ED policy, announced last year, in six states.

It calls for Anthem to reject ED claims when a patient goes to the ED for an issue that’s later considered not an emergency.

Anthem officials make that decision after a later review.

The payer is hoping the policy will nudge patients to less expensive care locations, such as urgent care centers, primary care offices and retail clinics or use 24/7 telehealth services.

Despite provider backlash, Anthem has stood firmly behind its ED policy, though agreed to make some exceptions. 

These include approving ED claims for patients sent to an ER by a provider, people who are from out of state or go to the ER on a weekend and those receiving certain medical care, like surgery, IV fluids or an MRI or CT scan in the ED.

The policy is one of multiple ways Anthem is looking to reduce healthcare costs.

Anthem also is not paying for imaging done in hospitals that could be done at lower-cost facilities.

The payer initially planned to also cut provider payments by 25% for separate evaluation and management services billed using CPT modifier 25 when a different procedure or service is performed on the same day.

The payer ultimately decided against the cut after provider backlash.

In a statement to Healthcare Dive earlier this year, Anthem said its policies seek to “reduce the cost of healthcare while simultaneously improving the quality and efficiency of the healthcare system for consumers.”

However, Paul Kivela, president of ACEP, said in a statement on Tuesday that Anthem’s ED policy is dangerous in that it expects people to know the difference between minor and potentially life-threatening conditions.

Kivela alleged that the payer ignored concerns from the ACEP and MAG.

“We felt we had no choice but to take action to protect our patients, and therefore are asking the federal court to force Anthem’s BCBS of Georgia to abide by the law and fulfill their obligation to their policyholders.”

MAG President Frank McDonald said 70% of Georgia doctors recently surveyed don’t believe an average patient “is knowledgeable enough to make judgments about what qualifies as a medical emergency."

“Even stopping to consider if it’s an emergency could mean the difference between life and death. Patients should never hesitate to seek emergency care out of fear of getting a large bill,” McDonald said.

The two physicians groups join Piedmont Hospital and five sister facilities that sued Anthem over the same policy earlier this year.

That lawsuit charged that Anthem’s policy will have “harmful consequences on access to medically necessary services, clinical integration, patient safety and quality of care.”

The policy has also been a sticking point in contract negotiations.

Saint Joseph Health System in Mishawaka, Indiana, objected and warned patients that it restricts patient choice and adds to patient costs.

Payers are watching how Anthem’s policy progresses.

Consistent provider opposition may cause others to avoid following Anthem’s lead.

However, if the insurer winds up reducing unnecessary ED use and costs, more insurers may feel the headache could be worth it in the long run.

Hospitals are also watching closely.

Any policy that may decline reimbursement and result in patients needing to pick up the tab could cause more uncompensated care and revenue cycle impacts for hospitals.


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