The health insurance giant’s ‘avoidable E.R.’ policy has their insured customers playing doctor and deciding between the emergency room or toughing it out at home or at urgent care.
Anthem, the second largest health insurance provider in the country, is under fire from doctors, hospital groups, health policy experts, politicians, and especially its customers for a new policy that aims to cut back on E.R. visits. The policy is now in effect for Anthem customers in Connecticut, Georgia, Indiana, Kentucky, Missouri, Ohio and New Hampshire. According to an Anthem spokesperson, the idea behind the policy is to help keep healthcare costs down for everyone. The company says that 5% of all E.R. visits are unnecessary and that (unneeded) emergency care costs 10 times more in an E.R. than it does in an urgent care or retail healthcare setting.
E.R. Flu Visits Not Covered Under Policy
In 2015, the company first began rolling out its unnecessary E.R. policy, notifying customers via a letter of the change. According to the new rule, Anthem will only cover emergency room visits based on whether or not the final diagnosis merited a trip to the emergency room. Things such as ankle sprains and suspected (but false alarm) heart attacks are not covered. The American College of Emergency Physicians was given a list of nearly 1900 diagnoses the insurance company would look at if an insured visits the E.R. One of the denied diagnoses is the flu (influenza), something that surprised the medical group given the severity of the illness last year. In fact, the CDC advises flu patients who have trouble breathing or fevers of 103 or higher to immediately go to the emergency room for treatment.
Critics of Anthem’s policy have asked how someone without a medical background would know whether or not their flu symptoms merited an E.R. visit if they felt truly awful or had a high fever. Given the reports of influenza-related deaths of otherwise healthy people, it makes sense for an average American who is ill with the flu to visit the E.R. if they are concerned.
Recently Updated Policy Still Doesn’t Address Patient as Doctor
Current law supports patients who believe they need to be seen immediately. Federal law passed in the 90s and upheld by 2010’s Affordable Care Act says that insurance companies cannot deny E.R. coverage if a non-medically trained person truly believes they need emergency care. But Anthem has seemingly skirted legal conflict by relenting and paying previously denied claims that insureds have fought upon appeal (typically with a lawyer). The insurance company has also recently amended their E.R. policy with several new inclusions.
The E.R. policy, updated on January 1, 2018, now agrees to automatically cover E.R. visits for patients who:
- are under 15 years of age
- live more than 15 miles from an urgent care facility
- are out of state at the time of the ’emergency’
- are admitted to the hospital for inpatient or outpatient treatment or observation upon visiting the E.R.
- visit the E.R. between 8 am on Saturday and 8 am Monday (likely due to urgent care clinics with weekday-only hours)
While the recent policy changes are certainly a step in the right direction, the policy still does not address how a typical patient would know the difference between indigestion and a stomachache vs. a heart attack.
BCBS of IL and Anthem Both Owned by BlueCross BlueShield Association
It is worth noting that Blue Cross Blue Shield of Illinois, one of the largest healthcare providers in our state, is under the same corporate umbrella as Anthem. The parent company of both Anthem BlueCross BlueShield and BlueCross BlueShield of Illinois is BlueCross BlueShield Association, a vast network of 36 separate health insurance companies. Anthem is the largest of all 36 companies within the company’s portfolio.
There is no known plan by BlueCross BlueShield of Illinois to enforce a similar policy, but it is foreseeable that other insurance companies are watching how Anthem’s policy impacts their customers and their own bottom line.