Anthem expands discretionary ED coverage policy to Indiana

Indianapolis-based Anthem will stop covering emergency department visits it deems unnecessary for Indiana policyholders, extending the discretionary policy recently enacted in Georgia and Missouri, according to an IndyStar report.

The policy aims to steer Anthem members with nonemergent ailments toward a primary care physician or an urgent care provider instead of costly ED visits.

"The ultimate goal of this is to encourage more efficient utilization of healthcare resources, relieve pressure on ERs that are already stretched thin and strengthen the relationship between our members and their primary care doctors, who are in the best position to influence the health of their patients," Anthem spokesperson Tony Felts told IndyStar.

Anthem has not determined when the policy will take effect in Indiana. The payer established a similar policy in three other states: Georgia, Kentucky and Missouri.

Indiana's policy is based on a list of about 300 codes it considers nonemergent, which it developed with four board-certified ED physicians, Mr. Felts told Becker's Hospital Review. Claims submitted for nonemergent care will be reviewed by an Anthem medical director, who will consider presenting symptoms bringing the patient to the ED and the diagnosis. Exceptions include ED visits for policyholders under age 14, patients with physician referrals to the ED, a lack of urgent care accessibility and if the visit occurs on a holiday or Sunday when nonemergent facilities may be closed.

Providers and patient advocates issued concerns about the policy, stating it may cause patients to postpone necessary care to avoid exorbitant medical bills.

Mr. Felts said approximately 10 percent of the 190,000 ED visits Indiana sees annually would be reviewed under the policy, and roughly 4 percent could be denied.

Editor's note: This article was updated Aug. 8 at 11:08 a.m. to provide additional information from Anthem.

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