Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

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Industry Orgs Fight Anthem’s Emergency Department Payment Policy

Anthem’s BCBS of Georgia violated federal law by retroactively denying emergency department payment and coverage, two physician groups argued in a new lawsuit.

Emergency services payment

Source: Thinkstock

By Jacqueline LaPointe

- The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) are suing Anthem’s Blue Cross Blue Shield (BCBS) of Georgia over a new policy that allows the payer to retroactively deny emergency department payment and coverage if the services are later deemed as non-emergent.

In the past year, Anthem implemented the emergency services payment policy in Georgia and five other states. The policy states that patients who seek care in the emergency department may face denied coverage for those services if the payer’s retrospective review finds that their diagnosis did not truly require emergency services.

Under the policy, emergency department providers also would not receive payment for the services rendered.

ACEP and MAG have criticized the policy’s implementation over the past year, arguing that individuals cannot self-diagnosis themselves for true emergencies and the policy results in delayed care and worse patient outcomes.

“We can't possibly expect people with no medical expertise to know the difference between something minor or something life-threatening, such as an ovarian cyst versus a burst appendix,” stated Paul Kivela, MD, FACEP, ACEP’s President. 

READ MORE: How Emergency Providers Can Adopt Alternative Payment Models

Seconds count in an emergency, stressed Frank McDonald, MD, MBA, President of MAG. “Even stopping to consider if it's an emergency could mean the difference between life and death. Patients should never hesitate to seek emergency care out of fear of getting a large bill,” he added.

With their efforts to reverse the policy by communicating with Anthem being unsuccessful, the industry groups are now bringing their complaints before a federal court.

In the lawsuit, the groups are arguing that the emergency services coverage policy violates the “prudent layperson” standard. The prudent layperson standard is a federal law mandating insurance companies to cover emergency care costs based on a patient’s symptoms.

ACEP and MAG emphasized that the federal law requires insurance companies to cover emergency services based on symptoms, not the final diagnosis. Therefore, Anthem’s BSBC of Georgia policy violates the prudent layperson standard.

According to the lawsuit, Anthem’s BCBS of Georgia has countered that their retrospective reviews of emergency services do not violate the prudent layperson standard.

READ MORE: 3 Strategies to Innovatively Advance Emergency Care Delivery

However, ACEP and MAG also contended that the payer’s ad campaign to curb emergency department visits and retrospective denials of provider payment have “caused confusion among their insureds as to the correct standard and their recent attempts to backtrack have not been sufficient to adequately inform providers or the public of the correct standard,” the lawsuit stated.

“As a result, providers and patients alike are operating in fear of denial of payment by Defendants when patients seek emergency department care.”

The lawsuit points to a larger issue with emergency department use. Spending on the emergency department has skyrocketed in the past decade, increasing 99 percent since 2009, according to most recent data from the Health Care Cost Institute (HCCI).

HCCI’s research also shows that emergency department spending is increasing despite little change in utilization.

“When use is flat and spending is up, the explanation is price for the most part. And in emergency rooms, it’s actually a combination of prices for all types of ER visits increasing and the number of ER visits that are considered high severity increasing,” explained HCCI Senior Researcher John Hargraves.

READ MORE: What Is Healthcare Revenue Cycle Management?

The emergency department may be one of the most expensive care settings, but for people with limited healthcare coverage, it may be their own option for care.

Health insurance premiums are set to significantly increase in 2019, with proposed price hikes between 10 and 90 percent. Individuals unwilling to pay the higher prices may forgo coverage altogether, especially after the repeal of the individual mandate that would have penalized them for not obtaining coverage.

Without coverage, providers may be left with the bill when they are trying to get paid for rendering services for those in need.

Steering patients to the most appropriate care settings has been a top priority for providers and payers alike. But recent policies to deny coverage and payment for emergency services have drawn controversy.

Rather than focusing on coverage, healthcare stakeholders have seen success with reducing emergency department spending through value-based reimbursement models. For example, Anthem reported a 3.5 percent decrease in emergency room costs under the Enhanced Personal Health Care Program, a value-based reimbursement model that transformed primary care practices.

Emergency department costs also fell at Brigham and Women’s Hospital in Boston after the organization implemented a care coordination program. Costs dropped 15 percent with the help of the program that relied heavily on community health workers to coordinate care and address social determinants of health.

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