A person in Missouri, walking along the side of a street, was suddenly struck by a car. The patient was taken to the emergency department, where multiple imaging studies revealed that despite bad scrapes and contusions, there were no broken bones. In another case, a patient who was potentially experiencing a stroke received tPA, a life-saving medication used to dissolve blood clots in the brain, and was admitted to the ICU.

In several other instances, Missourians have sought care in the ED for what they thought were broken bones.
Indianapolis-based health insurer Anthem denied payment for each of these cases under its new program meant to curb inappropriate ED use, according to emergency physicians and hospital administrators in Missouri, where the policy took effect in June.

Under the controversial policy, which nabbed plenty of headlines when it was rolled out in some states in mid-2017, Anthem won’t cover ED visits for conditions that the insurer decides were not emergent after a review.

Now, several months after the policy went into effect in Missouri and Georgia—it was rolled out in certain parts of Kentucky in late 2015—hospitals and patients are feeling the impact. Hospitals say the claim denials are piling up, and they’re forced to go through burdensome appeal processes. Patients are reeling from large medical bills for conditions they believed were emergencies. And emergency physicians worry that the policy will have a chilling effect on patients seeking care in an emergency, which could lead to worse health outcomes.

“If they get burned one time by a large bill, the next time they will delay going to the ED when they really need to be there,” said Dr. Jonathan Heidt, an ED doctor and president of the Missouri chapter of the American College of Emergency Physicians. “They are going to have a worse outcome from their illness or injury, or it could even lead to a patient death because they were too scared to go the ER for getting a large bill.”

Insurers and self-insured employers have long tried to encourage plan members to seek care at lower-cost settings. They usually do this by providing incentives, such as lower co-pays, if the patient chooses an urgent-care center over an emergency room when accessing medical care.

Anthem’s ED policy, which will expand to Indiana, New Hampshire and Ohio next year, takes the concept much further by denying payment altogether based on a retrospective view of a claim. Anthem said the policy is meant to promote delivering non-emergent care in the appropriate setting, such as retail or urgent-care clinics, or via telehealth. The insurer will cover non-emergent care in the ED if there is no clinic within 15 miles of a patient and a nurse is available to help plan members decide where to seek care. The policy applies only to commercial members, not Medicare, an Anthem spokeswoman said. Anthem also recently started denying coverage for MRI and CT scans on an outpatient basis in hospitals.

Anthem implemented the ED program because of “an uptick in emergency room visits for non-emergency treatment, despite education campaigns to inform the public about the costs and inconvenience of going to the ER for non-emergent care,” the spokeswoman said in an email. She added that in Missouri, for instance, ED visits have increased 20% since 2014, and many of those were for non-emergency ailments, including itchy eyes from seasonal allergies, treatment for ingrown toenails and suture removal.

The policy “doesn’t reflect the reality of the situation facing physicians and patients. Sometimes we need to do a fair number of tests to figure out if a patient’s condition is emergent or not. It’s not fair to expect patients to know,” said Dr. Laura Burke, an emergency physician and researcher at Beth Israel Deaconess Medical Center in Boston.

Diagnostic codes rarely tell the whole story, physicians said. A patient who shows up in the ED with chest pain could be having a heart attack, or the patient could be suffering from heartburn, Heidt said. It may take tests to determine what’s really going on. Deciding whether the ED visit deserves payment based on the final codes fails to take into account the circumstances surrounding a patient’s choice to go to the ER.

“They are not looking at any medical records at all. It’s difficult enough to determine what a patient was thinking based off an ER note, let alone just ICD-10 codes,” Heidt said.

A Missouri Hospital Association analysis of Anthem’s list of more than 1,900 diagnostic codes for avoidable ED services found that only 15% of the codes are classified as non-emergent when compared against the widely accepted New York University ED classification algorithm. Of those, fewer than 100 codes of the total 1,900 on the list are considered non-emergent beyond a doubt.

An Anthem spokeswoman said that particular list pertains to Missouri only and is outdated, though she would not provide the updated list, adding that the list is “continually evolving based on experience and further evaluation.”

Nine diagnostic codes on Anthem’s list deal with arm pain. In a letter to the American Heart Association sent late October, the Missouri hospital and medical associations explained that the average person may suspect that symptoms of arm pain could mean a heart attack. In 2016, almost 4,500 ED visits in Missouri had an initial diagnosis related to arm pain. Of those, 1 in 3 patients was diagnosed with a secondary cardiovascular condition.

Physicians are concerned that Anthem’s policy violates the long-standing prudent layperson standard, which is a law in 47 states and included in the Affordable Care Act. The standard gives patients protection to seek emergency care and hospitals’ assurance that they will be reimbursed. It holds that ED insurance coverage should be based on whether a prudent layperson, defined as someone with reasonable medical and health knowledge, could reasonably expect their health to be in jeopardy in an emergency, and not based on the final diagnosis codes.

Anthem said its policy complies with this standard.

But even when hospitals come out on the winning end of a disputed claim, they are coming up short.

A patient recently visited Cedar County Memorial Hospital, a critical-access facility in El Dorado Springs, Mo., with symptoms of gastrointestinal illness, dehydration and fainting. The patient had initially gone to a local clinic where a provider directed her to visit the ED. Anthem denied coverage for the visit, but later overturned the decision after an appeal. Jana Witt, Cedar County’s CEO, said the hospital has yet to receive payment, however.

“It does take a substantial amount of time to deal with fighting a denial like that,” Witt said. But patient outcomes are her primary concern. “The patient actually was experiencing a gastrointestinal illness, dehydration, and fainting—how is she to judge? Anthem’s policy is leaving that patient to decide, and they don’t have the knowledge to do so.”
Of course, some ED visits are avoidable. U.S. healthcare spending continues to climb, topping $3.2 trillion in 2015, or nearly $10,000 per person, according to the CMS. Emergency department spending is a piece of that, albeit a small part, despite public belief to the contrary. ED visits rose to a record high of 141.4 million in 2014, according to the Centers for Disease Control and Prevention. But the CDC also found that only 4.3% of ED visits were because of non-urgent symptoms that year. Other studies back that up.

Anthem has not disclosed how much of its claims costs come from ED visits. And it’s unclear how the policy will affect hospitals’ bottom lines in the long run. The revenue hospitals receive from emergency care varies by hospital and depends on payer mix, contracted rates with insurers, and other factors.

Hospitals and associations are now collecting stories of patients whose claims for emergency care have been denied by Anthem. Georgia’s insurance department has also said it is tracking consumer complaints related to Anthem’s policy. Because the policy is new and so far has been implemented in only a few states, it’ll be hard to bring enforcement action against Anthem, said Laura Wooster, ACEP’s associate executive director of public affairs.

Herb Kuhn, the Missouri Hospital Association’s CEO and a former CMS official, fears the policy will trigger a “cat and mouse game between healthcare providers and insurers,” forcing providers to seek legislative changes to block insurers from implementing policies that discourage ED use.

“Rather than working together on what we all ought to be—that coordinated care is better than uncoordinated care—instead, we’re all just chasing one another, trying to go to regulators and legislators to legislate protections in areas like this,” he said.