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Anthem Tweaks Policy On Non-Emergency ER Visits

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Health insurer Anthem will start paying for some emergency room visits that they deem "non-emergencies" following pushback from ER doctors and patients.

Last year, Anthem in several states stopped paying for emergency room visits, when they deemed that the patient was not actually having an emergency. This applied to people with private insurance coverage. The policy started in Kentucky in 2015, though emergency room doctors report a big uptick in denials last summer.

As a result of the policy, Anthem enrollees are stuck with emergency room bills that the insurer will not pay.

“We have hundreds of cases where people with conditions, where I don’t know in what universe you wouldn’t think they’re emergencies, have been denied,” said Wes Brewer, former president of the Kentucky chapter of the American College of Emergency Physicians.

According to data from the Centers for Disease Control and Prevention, emergency room visits increased to a record high in 2014, at 141.4 million visits. That same year Kentucky expanded Medicaid and people were able to buy insurance on the state-based exchange.

Anthem spokesman Jeff Blunt said in a statement that the company's policy attempts to rein in the increase in emergency room visits.

“Anthem’s avoidable ER program aims to reduce the trend in recent years of inappropriate use of ERs for non-emergencies,” Blunt said in a statement. “But as of January 1, 2018, we have implemented a series of ‘always pay’ exceptions consistent across all of our markets where the program is in place.”

The new policy means some of these unpaid claims will be paid, dating back to 2015 and moving forward. Anthem said it will pay a claim if:

  • A patient is sent to the ER by another provider, including an ambulance
  • The patient is under 15 years old
  • The patient’s home address is more than 15 miles from an urgent care center
  • The visit occurs between 8:00 p.m. Saturday and 8:00 a.m. Monday, or on a major holiday
  • The patient is traveling out of state
  • The patient received any kind of surgery
  • The patient received IV fluids or IV medications, an MRI or CT scan
  • The ER visit is associated with an outpatient or inpatient admission

Ryan Stanton, an emergency room doctor in Lexington, said many people show up in the emergency room because they can’t get into a primary care practice. Almost 60 percent of the ER visits in 2014, according to CDC data, occurred after business hours, implying primary care practices were closed.

“Many times these folks are coming to the ER because they have nowhere else to go,” Stanton said. “They don’t have access to primary care. The average [wait] time, if you call your primary care physician, is 20 days.”

Both Brewer and Stanton acknowledged there are patients who use the emergency room unnecessarily, but they agree that Anthem's strategy isn’t the right way to approach the problem. The policy penalizes the patient, and could drive patients to avoid the emergency room even if they think they might need to go.

“These groups that are trying to decrease the use of the emergency department are doing it on the back end and not making prior education or resources readily available,” Stanton said.

Lisa Gillespie is WFPL's Health and Innovation Reporter.

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