Anthem’s ED policy prompted a Missouri law that defines a medical emergency.

The Upshot column in the New York Times on May 19 focused on Anthem’s experiment with denying emergency room visits, arguing that patients should have known that ED care was unnecessary.   

One of the anecdotes in the column perfectly illustrates the giant flaw in Anthem’s policy. When “Jason” became short of breath in 2015, he went to the emergency room. He was treated for a panic attack. Two days later, again experiencing shortness of breath and fearing he had heart problems, he returned. His pulse was over 150. How did Anthem handle these two visits? 

The first visit was denied because it was coded as a panic attack. The second visit was allowed because it included the diagnosis of breathing trouble. To Anthem’s credit, when Jason appealed the denial, that first visit was paid. 

But think about how illogical this situation is. The first time he had symptoms, they denied the care, but they actually allowed the repeat visit. Why? Anthem focused on the final diagnosis code, not the symptoms. It should be obvious to any rational person that the final diagnosis isn’t material for determining whether the patient was acting reasonably in visiting the ED. 

Chest pain can be caused by a range of conditions that could include anything from an MI to gas. Obviously, the latter isn’t an emergency. However, a layperson’s ability to determine which of these conditions is actually present is presumably very limited. 

In fact, as a layperson, if I attempted to help you determine whether you had an MI or gas, I would be breaking the law: specifically, practicing medicine without a license. Non-physicians are not supposed to make medical judgments. Nevertheless, according to the New York Times and the American College of Emergency Physicians study on which the Times’ story was based, Anthem conducted an experiment in six states – Kentucky, Missouri, Indiana, Ohio, New Hampshire, and Connecticut – performing reviews based solely on the final diagnosis and without the review of medical records.

The good news is that Anthem has reverted to its previous policy. During the experiment, approximately 3 percent of emergency visits in Missouri were being denied. Anthem has now returned to paying well over 99 percent of emergency visits.

As a result of Anthem’s policy, Missouri has passed a new Senate bill: 982. That law defines an emergency medical condition as one that is sudden and would lead a prudent layperson to believe that immediate medical care is required.

The bill does something else very interesting. It requires healthcare professionals and insurance companies to enter into binding arbitration when a health professional provides emergency care to an out-of-network patient and the insurer and healthcare organization are unable to agree on reimbursement. The professional is prohibited from sending a bill to the patient in excess of whatever the arbitration process determines. 

There is definite logic to this provision. When a patient has insurance that covers an emergency medical condition, one thing is clear. If they go to the emergency room, either the care provided is reasonable and the insurer should pay, or if the care is unreasonable, the fault lies with the professional or facility. In either case, the patient should not be responsible for the bill.

I recommend that readers adopt this policy. In a fight with an insurer about reimbursement, consider telling the patient that if the insurer won’t pay, they won’t face liability. Note that in many situations, telling a patient that you will accept insurance payment as payment in full can void insurance coverage. A future article will explain why this situation is different.

The bottom line is that when an insured person reasonably thinks they have an emergency medical condition, both the law and common sense say that the patient shouldn’t be responsible for the cost of the medical care.


Program Note:

Listen to David Glaser every Monday on Monitor Mondays, 10-10:30 a.m. ET.


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