Anthem's policy to retrospectively deny coverage for emergency care it deems nonemergent could land 1 in 6 patients with denied claims if widely adopted, according to a study published in JAMA Network.
For the study, researchers analyzed emergency department visits from the National Hospital Ambulatory Medical Care Survey. The data, which included visits from 2011-15, represented commercially insured patients between the ages of 15 and 64 who sought emergency care for an ailment Anthem would have defined as nonemergent.
Researchers found 15.7 percent of commercially insured adult ER visits could have been denied if Anthem's policy was used by other insurers. About 40 percent of those visits led to ER-level care, 24.5 percent were first triaged as urgent or emergent, and 26 percent resulted in at least two diagnostic tests. Notably, the potential denials shared the same presenting symptoms as 87.9 percent of commercially insured adult ER visits.
"Anthem’s nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient's perspective," the researchers concluded. "This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial."
In July, data provided by Anthem to Sen. Claire McCaskill, D-Mo., indicated that in three states the insurer denied 12,200 claims during the second half of 2017 on the grounds the ER visits were "avoidable." The denials reflected about 5.8 percent of total ER claims submitted in the three states — Missouri, Kentucky and Georgia — during this period. However, when patients challenged the denials, Anthem proceeded to reverse itself and pay the claims most of the time.