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Insurers could deny 1 in 6 ER visits if they were to adopt Anthem policy, JAMA says

Anthem set a policy to deny coverage if it is determined through the discharge diagnosis that the visit was unnecessary.

Susan Morse, Senior Editor

If Anthem's policy of denying what it deems as unnecessary emergency room visits was universally adopted by other insurers, nearly one in six visits to the ER by commercially insured adults could be denied coverage, according to a study released by JAMA, the Journal of the American Medical Association.

WHY THIS MATTERS

The emergency room is the most expensive setting for care. Value-based care is moving patients away from ER visits when avoidable.

The JAMA study shows health insurers are increasingly adopting policies to reduce emergency room visits they consider unnecessary.

Last year, Anthem, one of the nation's largest insurers, set policy to deny coverage if it determined through the discharge diagnosis that the visit was unnecessary.

Anthem said it was striving to make healthcare more affordable.

But physician groups, including the American Medical Association, objected to the policy. The American College of Emergency Physicians said members, and even doctors, don't always know when a medical condition is a real emergency until after the patient is seen.

After getting numerous objections, Anthem amended its policy. As of January 1, the insurer said, it would always pay for ER care if the visit is based on a referral from a provider or ambulance; it services patients under the age of 15; the visit is associated with an outpatient or inpatient admission; the emergency room visit occurs because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away; the visit occurs between 8 a.m. Saturday and 8 a.m. Monday; and when the patient receives surgery, IV fluids, IV medications, or an MRI or CT scan.

In 2017, Anthem implemented the policy in Georgia, Missouri, and Kentucky, expanding in 2018 to New Hampshire, Indiana, and Ohio, with expansion to more states underway.

PROPOSAL

JAMA set out to determine the impact of Anthem's policy through a sampling of ER visits by commercially-insured patients ages 15 to 64 between 2011 and 2015.

It found that 15.7 percent of commercially insured adult ER visits were denied based on diagnosis.

Also, the study said, from a patient perspective, the ER visit was necessary. The most common symptoms prompting a visit were abdominal pain, chest pain and headache.

Also, in up to nine of 10 visits patients presented the same symptoms between emergency and non-emergency level care.

However, the study also found that, while 10 to 20 percent of emergency room visits were reviewed by Anthem for denial, only 4 to 7 percent were ultimately denied.

WHAT ELSE YOU NEED TO KNOW

Anthem's policy of retroactive coverage denial based on discharge diagnosis has led to a congressional investigation by Sen Claire McCaskill of Missouri for potential violation of the prudent layperson standard, JAMA said.

Another recent JAMA study looked at ER use among patients with a mental health diagnosis. It found that prior patient visits and patient illness severity associated with a mental health diagnosis could be important contributors to increased ER use.

THEIR TAKE

The cost-reduction policy could place many patients who reasonably seek ER care at risk of coverage denial, the study said.

The policy cannot accurately identify unnecessary visits, as up to 40 percent of the visits that were considered non-emergency were likely appropriate ER visits. 

The assumption underlying Anthem's policy is that patients should be able to determine whether their symptoms warrant emergency care.

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

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