Skip to main content
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Digital Health
    • Transformation
    • ESG
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Blogs
    • AI
    • Deals
    • Layoff Tracker
    • HIMSS 2023
  • Opinion
    • Breaking Bias
    • Commentaries
    • Letters
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • 40 Under 40
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top Innovators
    • Diversity in Healthcare
      • - Luminaries
      • - Top 25 Diversity Leaders
      • - Leaders to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Hospital at Home
    • - Workplace of the Future
    • - AI and Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Sponsored Video Series - One on One
    • Sponsored Video Series - Checking In with Dan Peres
  • Data & Insights
    • Data & Insights Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • Newsletters
  • MORE+
    • Contact Us
    • Advertise
    • Media Kit
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Providers
July 17, 2018 12:00 AM

Anthem ED policy draws lawsuit from docs

Shelby Livingston
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print

    Health insurer Anthem has run into more trouble over its controversial emergency department policy that's leaving patients on the hook for big medical bills. The American College of Emergency Physicians and the Medical Association of Georgia together sued Anthem's Georgia subsidiary on Tuesday in a bid to force the insurer to kill the policy.

    Anthem Blue Cross and Blue Shield of Georgia has been sued over the ED policy before. In February, Atlanta-based Piedmont Hospital and five sister hospitals filed lawsuits claiming Anthem's policy of denying coverage for non-emergency ED visits after the fact violates Georgia law. But while Anthem tweaked the ED program in February in response to outrage from state legislators and the public, it has refused to rescind it.

    So ACEP—after months of back-and-forth with Anthem detailed in the lawsuit—is jumping into the mix. "This is a first step in the process and depending on how things play out, we would entertain filing in other states where Anthem is (implementing) the policy," said Laura Wooster, associate executive director for public affairs in ACEP's Washington office.

    Anthem's ED policy is active in six states. ACEP filed its first suit in Georgia because the state's medical association came forward as a potential partner in a lawsuit, Wooster explained.

    The lawsuit filed in federal court in Atlanta alleges that Anthem's ED policy harms healthcare providers and their patients. Anthem is denying providers the reimbursement they are owed for providing emergency services and causing providers to spend time and effort responding to "inappropriate denials," the suit alleged.

    ACEP and the Medical Association of Georgia argue the policy violates a slew of laws, the first being the "prudent layperson" standard, a law in most states and included in the Affordable Care Act that gives patients protection to seek emergency care and hospitals' assurance that they will be reimbursed. The standard requires insurers to cover the cost of emergency care based on symptoms, not final diagnosis.

    ACEP and other opponents of Anthem's policy say the insurer decides whether to deny or pay for emergency care based on a secret list of diagnostic codes that it won't publicly release. The complaint also states that Anthem did not request medical records when determining ED coverage, and instead relied on the codes provided in the claim only. But Anthem has said it is now reviewing records.

    ACEP and the medical association also allege that Anthem's policy violates the Emergency Medical Treatment and Labor Act, which requires emergency physicians to see anyone who comes to a hospital's emergency department. And they say it runs afoul to the Employee Retirement Income Security Act of 1974, or ERISA, as well as Title VI of the Civil Rights Act of 1964 for disproportionately affecting "members of protected classes."

    Anthem first rolled out its ED policy in certain parts of Kentucky in 2015 before implementing it in Georgia and Missouri in 2017. It later expanded the policy to Indiana, New Hampshire and Ohio. It had planned on rolling out the program in 2018 to all of the states where it operates health plans, but it's unclear if that's still the case.

    Anthem declined to comment on the lawsuit.

    At its core, Anthem's policy is about reducing the insurer's ED costs by paying for fewer claims. Seeking care in a hospital ED is undoubtedly more expensive that getting those same medical services at a doctor's office or walk-in clinic. And some ED visits are avoidable, though just how many varies widely depending on the source.

    Notably, the lawsuit mentions that Anthem Blue Cross and Blue Shield of Missouri's senior clinical officer, Dr. Jay Moore, said in a meeting with ACEP officials that 30% to 40% of ED visits are avoidable. But the Centers for Disease Control and Prevention has estimated that just 4.3% of ED visits in 2014 were for non-urgent symptoms.

    But opponents of the policy argue that Anthem is going about reducing costs the wrong way. It is putting the burden on patients' shoulders to self-diagnosis whether their symptoms are indeed an emergency at a time when the patient may be stressed. The prospect of being saddled with a huge bill could lead patients to skip care.

    "Just having this policy in place presents a chilling effect to patients and their decision to seek care for what could potentially be an emergency," Wooster explained. "It could result in them being left with their entire bill uncovered."

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    diversity
    Health equity execs leveraging academic roles to drive long-term change
    Patrick Blair InnovAge
    PACE could expand amid possible nursing home closures: InnovAge CEO
    Most Popular
    1
    Centene to lay off 2,000 workers
    2
    How health systems are battling price-gouging allegations
    3
    Senate advances bill to temporarily aid hospitals, health centers
    4
    Elevance, Blue Cross Louisiana halt $2.5B proposed deal
    5
    Tower Health to sell urgent care centers, close others
    Sponsored Content
    Modern Healthcare A.M. Newsletter: Sign up to receive a comprehensive weekday morning newsletter designed for busy healthcare executives who need the latest and most important healthcare news and analysis.
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Help Center
    • Advertise with Us
    • Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Digital Health
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • ESG
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Blogs
      • AI
      • Deals
      • Layoff Tracker
      • HIMSS 2023
    • Opinion
      • Breaking Bias
      • Commentaries
      • Letters
      • From the Editor
    • Events & Awards
      • Awards
        • Nominate/Eligibility
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • 40 Under 40
        • Best Places to Work in Healthcare
        • Excellence in Governance
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top Innovators
        • Diversity in Healthcare
          • - Luminaries
          • - Top 25 Diversity Leaders
          • - Leaders to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Hospital at Home
        • - Workplace of the Future
        • - AI and Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Sponsored Video Series - One on One
      • Sponsored Video Series - Checking In with Dan Peres
    • Data & Insights
      • Data & Insights Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • Newsletters
    • MORE+
      • Contact Us
      • Advertise
      • Media Kit
      • Jobs
      • People on the Move
      • Reprints & Licensing