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Anthem amends ER policy but stands behind decision not to pay for avoidable emergency care

As of Jan. 1, Anthem said it would always pay for emergency room visits based on certain conditions.

Susan Morse, Senior Editor

Responding to numerous objections of its emergency room policy, Anthem has tweaked its decision not to cover ER visits if the medical condition is not an emergency.

Providers have said it puts patients in harm's way when they have to decide whether their conditions constitute an emergency.

[Also: Georgia hospital system sues Blue Cross Blue Shield for Anthem imaging policy]

As of January 1, Anthem said it would always pay for ER visits based on certain conditions. These exceptions include provider and ambulance referrals, services delivered to patients under the age of 15,  visits associated with an outpatient or inpatient admission, emergency room visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away, visits 8 a.m. Saturday and 8 a.m. Monday, and any visit where the patient receives surgery, IV fluids, IV medications or an MRI or CT scan.

"We will continue to review this list and may expand it," Anthem said in a statement. "We are applying our new and enhanced procedures to previously denied claims, and will overturn decisions where the new procedures would have resulted in an approval,"

Additionally, Anthem is requesting medical records from the hospital as part of the initial review process.

However, the insurer said it stands by its belief that emergency rooms are an expensive place to receive routine care. Anthem said it is striving to make healthcare more affordable and to encourage consumers to receive care in the most appropriate setting. 

"Anthem's avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies. We recognize, however, that there are ways to further improve and enhance the program," Anthem said.

Anthem has implemented the avoidable ER policy in Georgia, Missouri, Ohio, Indiana, New Hampshire and Kentucky.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com

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