Under Anthem Policy, 1 in 6 Could Be Denied ED Coverage

Anthem Blue Cross Blue Shield’s policy of denying emergency coverage for nonemergent diagnoses could place many patients at risk of coverage denial. According to a new study, more than 1 in 6 commercially insured adults would be denied coverage if the policy was adopted by all other commercial insurers.

Policies, like Anthem’s, that apply financial disincentives for emergency department (ED) visits that could presumably be cared for in alternative settings have emerged as strategies to reduce ED care use in response to increases in ED visits and payment for these visits by insurers and patients.

Under Anthem’s policy, coverage is denied for ED visits deemed unnecessary based on a prespecified list of nonemergent conditions. The policy is currently is active in 6 states: Indiana, Kentucky, Missouri, New Hampshire, Ohio, and Georgia.

However, while these visits are often labeled as inappropriate or nonemergent, a prior study found that nearly 90% of all ED visits in the United States had the same presenting symptoms as ED visits with diagnoses considered primary care—treatable, indicating that there is no clear link between many symptoms and discharge diagnoses considered primary care–treatable.

“The news media have reported individual cases of patients with Anthem insurance presenting to the ED with concerning symptoms such as abdominal pain or severe headache only to have coverage denied after ED evaluation ruled out emergent conditions,” wrote the authors. “As Anthem remains one of the largest health insurers in the nation, it is important to examine the population that may be affected if other insurers across the nation adopt similar policies of diagnosis-based retroactive coverage denial for ED visits.”

Using a national sample of ED visits among those aged 15 to 64 between January 2011 and December 2015, the authors determined that 4440 of the 28,304 ED visits could be denied coverage. Among those visits, 39.7% received ED-level care: 24.5% were initially triaged as urgent or emergent and 26% received 2 or more diagnostic tests.

“Even triage nurses, the most experienced ED nurses, considered nearly one-quarter of visits with nonemergent ED diagnoses urgent or emergent prior to a full clinical evaluation,” noted the authors.

Because Anthem’s policy requires patients to determine if their symptoms are nonemergent, the authors also determined how many commercially insured ED visits shared the same symptoms as the visits that resulted in nonemergent diagnoses that could be denied coverage.

Nearly 9 out of 10 (87.9%) of commercially insured ED visits presented with the same primary symptoms as the visits that resulted in nonemergent diagnoses, and among these visits, 65.1% received ED-level care: 43.2% were triaged as urgent or emergent, 51.9% received 2 or more diagnostic tests, and 9.7% were admitted or transferred.

“The main limitation of retrospectively judging the necessity of ED care is that the determination is based on information not available to patient prior to the medical evaluation,” wrote the authors. “When patients become acutely ill, they must decide whether to seek care (and, if so, when and where) based not on a diagnosis but on the symptoms they are experiencing.”

Reference:

Chou S, Gondi S, Baker O, et al. Analysis of a commercial insurance policy to deny coverage for emergency department visits with nonemergent diagnoses [published online October 19, 2018]. JAMA Network Open. 2018;1(6):e183731. doi:10.1001/jamanetworkopen.2018.3731.