Anthem Stops Paying for Non-Emergency ED Visits: 4 Takeaways

One health insurer’s decision to no longer pay for non-emergent visits to the emergency room in some states has sparked much criticism. Anthem Blue Cross Blue Shield has had this policy in place in Kentucky, Missouri, and Georgia and recently expanded it to Ohio, Indiana, and New Hampshire in January. The health insurer said in a statement that the goal of the measure is to “ensure access to high quality, affordable healthcare.”  

Here are four takeaways about the new policy.

1. Insurers are struggling with high emergency department use-and costs associated with it.

According to Anthem, the program “aims to reduce the trend in recent years of inappropriate use of emergency rooms for non-emergencies.”

Richard L. Trembowicz, JD, associate principal, ECG Management Consultants, healthcare/insurance consultants, says under the ACA more people have obtained healthcare coverage through the exchanges and Medicaid. They’re using emergency rooms more than others because they aren’t familiar with the best way to access care when a sudden onset of symptoms occurs. Many don’t have established primary care physician relationships, and don’t know where to go for urgent care, he says. In addition, in general many people don’t know how to determine if symptoms are an emergency or not.

Given all of this, and the fact that a number of studies and reports indicate that approximately 3% to 5% of emergency room visits are “avoidable” and do not constitute an emergent situation, Trembowicz says Anthem has valid reasons for its policy.

Jay Wolfson, DrPH, JD, professor of Public Health, Medicine and Pharmacy and associate vice president of Health Policy, Law and Safety, USF Health, University of South Florida, Tampa, FL, says demographics-such as no nearby, familiar/trusted alternative for healthcare services, lack of insurance coverage, employment/child care obligations that only permit evening care, seasonal morbidities such as influenza, and gaps or lack of healthcare coverage also fuel visits to emergency departments.

2. The policy could have wide-ranging effects.

Regarding the impact of Anthem’s policy on its members, Wolfson says people may be deterred from seeking emergency care when really needed, hospitals could turn patients away, or some hospitals may decide they can’t afford to operate an emergency department.

In speaking with individuals who were denied coverage by Anthem for emergency room visits, Ryan A. Stanton, MD, emergency physician, Lexington, KY, and spokesman for the American College of Emergency Physicians, says they will think twice before going to the emergency room again because they can’t risk getting a high bill if coverage is denied. “Something bad could happen as a result of this; people could die,” he says.

Trembowicz says if members’ claims are denied, they will have to be diligent about understanding their appeal rights under their health plan and state law, and be willing to put in the time and the effort to appeal a claim.

Next: More guidance needed

3. Primary care physicians may need to provide more guidance. 

Many highly volatile conditions may not be easily classified as non-emergent, such as severe headaches that are signs of stroke, chest pain signaling a heart attack, or respiratory distress that is a severe asthmatic reaction, says Joseph Smith, MPH, senior research associate, USF, making it difficult for people to decide whether or not to go the emergency room.

Stanton says patients should be encouraged to contact their primary care physician or insurance company to advise them on what level of care to seek when they are in doubt, unless they are having a time-sensitive emergency. 

4. More states are likely to be affected.

Trembowicz predicts that Anthem will extend its policy to more states. “It will most likely be adopted in states with fewer consumer protections beyond the insurance contract,” he says. “In states with more extensive consumer protections (e.g., unfair or deceptive acts or practices statutes), or more activist insurance regulators, the insurer may be required to obtain and review the full medical record to understand symptoms and conditions present on admission, and not just rely solely on information in the claim before adjudicating the claim, which is a more expensive process.”

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.