Anthem updates 'always pay' conditions under ER policy: 5 things to know

Anthem increased the number of "always pay" exceptions under its controversial discretionary emergency care policy.

Here are five things to know about Anthem's updates.

1. Under Anthem's policy, which is effective in several states, Anthem will review diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, Anthem may not cover the ED visit. The move aims to deter patients from using costly ED services for treatment that could be administered in less expensive urgent care or primary care settings.

2. Following backlash from physicians and lawmakers, Anthem expanded its exemptions for the policy in Missouri, Georgia, Ohio, Indiana and Kentucky. The new exemptions include patients who receive surgery, IV fluids or IV medications, MRI or CT scans, or hospital admissions, among other exclusions. 

3. Anthem said it will "take that new list of exceptions and look back at claims that were previously denied. If one of those conditions was present, we will change the decision and pay the claim according to" patients' benefits.

4. Anthem will review claims from Missouri since June 2017, claims from Georgia since July 2017, and claims from Kentucky since 2015.

5. Paul Kivela, MD, president of the American College of Emergency Physicians, said the changes "do not address the underlying problem of putting patients in a potentially dangerous position of having to decide whether their symptoms are medical emergencies or not before they seek emergency care, or pay the entire bill if it's not an emergency." ACEP representatives have argued Anthem's policy violates federal law.

More articles on payer issues:
Why Walgreens now appears less likely to acquire Humana or WellCare
Aetna: Former medical director misrepresented our denial process
BCBS of Minnesota CEO to step down: 3 things to know

© Copyright ASC COMMUNICATIONS 2021. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.

 

Featured Whitepapers

Featured Webinars