Controversial ER Policy Could Result In Denials For As Many As 16% Of Visits

By Consumers For Quality Care, on October 26, 2018

A new analysis shows that the controversial Anthem emergency department policy could result in the denial of claims for as many as 16 percent of visits if expanded nationally, Reuters reports. The study, which was reported in JAMA Network Open, found that consumers could be denied even when their symptoms are identical to symptoms of actual emergencies.

Dr. Shih-Chuan Chou applied Anthem’s policy criteria against a national database of patients who visited the ER. The analysis included commercially insured patients aged 15 to 64 who sought ER care between 2011 and 2015. Of 28,304 visits, more than a third had a final diagnosis that included a non-emergency condition, as classified by Anthem’s denial criteria.

After excluding cases with a non-emergency diagnosis that probably would have been covered, the researchers still found that 4,440 claims likely would have been denied.

Yet, when the researchers analyzed the patients’ symptoms in all the ER cases, they found that chest pain, abdominal pain and headache were among the most common for those who did ultimately need emergency-level care, and for those who would have been denied.

Insurance companies search for ways to  discourage people from over frequenting ERs, but  consumers, advocates, physicians, and lawmakers are wary of a policy that might lead patients to ignore potentially devastating symptoms. Dr. Albert Wu, who works at Johns Hopkins Bloomberg School of Public Health and was not a part of the study, said that Anthem’s policy is flawed because while “it will probably decrease inappropriate visits, it will also decrease appropriate visits.”

“It’s a really unreasonable expectation to have patients self-triage,” he said.

Chou highlights that something like belly pain could be a minor ailment or something more severe:

“If someone presents with belly pain, they’re going to get a CT scan,” he said. “If the pain is very sharp, it could be a ruptured cyst or appendicitis. I don’t know how you could expect patients to be able to differentiate the two on their own.”