Having won their fight on another payment policy last week, the American Hospital Association and two other national organizations are asking Anthem to rescind its coverage policies for emergency care and advanced imaging services.
In a February 27 letter to Anthem Vice President and Chief Clinical officer Craig Samitt, MD, the AHA, American College of Radiology and American College of Emergency Physicians, criticized Anthem for enacting the reimbursement policies without provider input or what they called concern for patient safety.
The letter cited examples of Anthem denying coverage based on its policy not to pay for emergency care if the treatment could have given in a more appropriate, less expensive setting.
In one instance, Anthem denied a claim for a woman who showed up at the ER for extreme abdominal pain and fever, believing she had a ruptured appendix. She had an ovarian cyst.
In another denied claim, a pedestrian had been hit by a car and was transported on a backboard by emergency medical personnel. He was found not to have suffered serious injury.
The Anthem denial notices said, "Emergency room services can be approved when a health problem is recent and severe enough that it needs immediate care such as a stroke, heart attack or severe bleeding," according to the letter.
"There are countless medical conditions beyond stroke, heart attacks or severe bleeding that still need immediate care," the letter said.
Also, the groups said, patients don't have the medical knowledge for self-diagnosis. Most of the time, clinicians need to conduct tests before being able to assess the level of care needed.
In addition, they object to Anthem's policy not to pay for hospital imaging services when a less-expensive on outpatient facility is available.
Anthem recently updated its imaging exemption list to include additional patients, but the policy removes radiology from the continuum of patients' care and treats the service as a commodity, going to the lowest-cost provider, they said.
"Anthem's decision to unilaterally eliminate an entire site of service outside of any contract negotiation cycle that defines 'in-network' providers is unprecedented and is not how parties in an ongoing business relationship should work together," the groups said. "We ask that Anthem rescind these policies …"
Anthem enacted its emergency department and outpatient imaging policies last year in certain states, saying it is trying to lower the high cost of healthcare.
Providers last week won their fight over another Anthem reimbursement policy. Anthem repealed its planned modifier 25 policy to cut payment by 25 percent for certain evaluation and management codes. The policy was to have gone into effect on March 1 across the company's commercial health insurance businesses.
More than 10 organizations argued their opposition to "any policy that excludes coverage for any site of service based primarily on insurer profit."
The insurer made the policy change in response to the strong opposition from provider and physician groups.