When an Emergency is not an Emergency – Changes in ED coverage policies

Mar 29, 2018 | Archive

For some patients, a visit to the emergency department may now come with unexpected costs, as health plans—including Medicaid—begin to roll out new policies that aim to discourage “preventable” visits to the ER. These policies have been met with mixed reviews, with many concerned about potential negative implications on overall patient health, patient financial responsibility and hospital revenue.

Anthem recently rolled out a new policy aimed at decreasing ER utilization for non-emergencies that could safely be treated in less-expensive care settings. The policy seeks to drive patients to use alternative locations such as primary care offices, retail clinics, urgent care centers and 24/7 telehealth resources for “minor ailments” such as symptoms of the common cold.

The policy initially launched in three states in late 2017—Georgia, Kentucky and Missouri—and expanded in 2018 to Indiana, New Hampshire and Ohio. It impacts only large employer fully-insured health plans and self-insured employer plans that have opted into the program; the policy does not impact Anthem’s Medicare or Medicaid populations.

Under the policy, more than 1,900 ICD-10 codes reportedly may no longer be covered for an ER visit. To determine coverage, Anthem will retrospectively review claim information and medical records.

Many physicians and provider organizations, including the American College of Emergency Physicians, are concerned about the negative impact this type of policy may have on patient health, considering only 3.3% of ER visits are considered avoidable. Critics argue this type of policy puts patients at risk because it requires the patients themselves to determine if their symptoms are classified as an emergency. This can be further complicated by the fact that many symptoms overlap diagnoses—some of those may be emergent in natures while others may not.

Others point out that patients may avoid visiting the ER—even in a situation where it is necessary for the best health outcome—if they have had past experience with denied claims.

In addition to these concerns, many critics also maintain that the policy directly contradicts two legal safeguards in place to protect patients:

  1. The Emergency Medical Treatment and Labor Act of 1986 (EMTALA). This federal law requires emergency departments to screen, stabilize or treat anyone showing up at the ER, regardless of their insurance coverage or ability to pay.
  2. “Prudent Layperson” Standard. This requires insurance companies to base reimbursement on a patient’s symptoms rather than final diagnosis. It centers on the idea that insurers must pay for ER services for any condition the “average person” would consider to be an emergency.

After backlash following the initial launch in late 2017, Anthem amended the policy for 2018 to include circumstances that will always be covered for a visit to the ER. This includes “provider and ambulance referrals; services delivered to patients under the age of 15; visits associated with an outpatient or inpatient admission; emergency room visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away; visits 8 a.m. Saturday and 8 a.m. Monday; and any visit where the patient receives surgery, IV fluids, IV medications or an MRI or CT scan.” Anthem has reported it will apply these conditions to previously denied claims and overturn decisions where it would have resulted in an approval.

Despite these changes, the policy revisions have done little to alleviate concerns, with many worried that Anthem will continue to expand the policy in new states and other insurers will adopt similar approaches. In fact, the State of Kentucky has announced it will launch a new model for its Medicaid expansion population, issuing members a monetary penalty between $20 and $75 each time the ER is used for “non-emergency care.”

At this point, we can only speculate how these types of policies will affect hospitals in the long run. What is certain is that it’s likely many patients will be unable to foot the bill for a visit to the ER. As a result of this approach, hospitals may be forced to deal with increasing claims denials and appeals processes, in addition to an increase in bad debt.