Sen. Claire McCaskill (D-Mo.) is taking on insurance giant Anthem over its controversial policy to deny coverage for emergency department treatment for cases that are later determined not to have been an emergency.
Anthem said it rolled out the policy change in Georgia and Missouri this past June. The insurer has said it began instituting the policy change in parts of Kentucky as well as far back as 2015, but some have raised doubts over those claims.
"We had no evidence that any claim was refused until about three or four months ago," said Dr. Ryan Stanton, an emergency physician in Lexington, Ky., and a spokesman for the American College of Emergency Physicians. Over the past four months, Stanton said the number of denials on claims by Anthem has been in the hundreds by providers all over the state.
"Our concern is that what this policy is going to do is encourage people to wait at home and let something get worse to the point where we can't do anything about it."
The problem involves the way Anthem reviews ED cases, according to Stanton. He said oftentimes the insurer will make a determination based solely on diagnostic ICD-10 codes instead of medical records. Once the denial is issued, a provider may appeal it, and it is only then when the insurer will request to review a patient's medical records, Stanton said.
For many larger providers, the process of repeatedly appealing every ED claim denial can be too costly and time-consuming, so the cost of services are either passed on to patients or consumed by the system as a part of its uncompensated care. For smaller and more rural hospitals, the accumulation of such bad debt can put providers in financial risk.
"If we don't fight and the patient doesn't fight, then Anthem wins," Stanton said. "They're just seeing how many balls they can throw and we're going to watch go by without taking a swing at them. So far they're doing pretty good."
Anthem did not immediately respond to requests for comment. The insurer has stated in the past that its decision to implement the policy had to do with increases it has experienced in claims for non-emergent ED visits in those states.
The policy affects only commercial plan members, not those covered under Anthem's Medicare plans.
In a letter sent to Anthem's CEO on Wednesday, McCaskill said the policy raised "serious concerns" about whether Anthem was in violation of state and federal laws that require insurance coverage be based on a patient's symptoms, not their final diagnosis.
"Anthem's policies are discouraging individuals from receiving needed care and treatment out of fear they may personally be fully financially responsible for the cost of treatment, even though they have insurance," McCaskill wrote.
In her letter, McCaskill referenced a Modern Healthcare article published earlier this month describing how Anthem refused to pay the hospital costs of a member who was struck by a car and taken to the ED, but only had minor injuries. Another patient's claim was denied after the person was treated for stroke symptoms, although it turned out the patient hadn't suffered a stroke.
"These denials jeopardize the health and safety of Missourians," McCaskill wrote.
McCaskill has requested Anthem provide all internal correspondence related to the company's decision to institute its policy, as well as any presentations to senior corporate management or government entities regarding emergency care utilization. Other documents requested include any complaint Anthem has received from any entity related to its emergency care coverage in Georgia, Kentucky and Missouri, communications the insurer received from hospitals about the policy, documentation related to the potential cost savings expected from the policy change, and any documents detailing possible exceptions to the policy.
McCaskill has asked the company to provide all documents no later than Jan. 19.
Anthem plans to implement the policy in Indiana, New Hampshire and Ohio beginning Jan. 1.
Stanton warned that the policy forces patients to diagnose themselves to avoid the risk of paying out of pocket for their ED visits. He feared such a scenario will increase their health risk.
"Unfortunately, we're going to end up having to send them coroner reports on things that were not evaluated because the patient didn't want to go the ER because they assumed Anthem wouldn't cover it," Stanton said.
