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ACEP Battles Anthem BlueCross BlueShield Policy That Jeopardizes Prudent Layperson Standard

Since early summer, ACEP has been working hard on behalf of its members to protect the prudent layperson standard by advocating for the reversal of a dangerous new policy being enforced by the insurer Anthem BlueCross BlueShield in six states.

First implemented in July in Georgia, Kentucky, and Missouri, and most recently expanded at the start of this year to Indiana, New Hampshire, and Ohio, the policy allows Anthem to retroactively deny coverage of emergency department visits that the insurer deems as “nonemergent.” Anthem uses a list of so-called nonemergent ICD-10 codes to flag emergency department claims for medical review, which is then performed by an Anthem-employed physician medical director. However, unlike the more customary review process, no patient chart is requested; the medical director simply reviews the claims form and the limited information it contains on the encounter to make a determination on whether to deny.

As a result, there have been denials that include a pedestrian struck by a vehicle who was taken to the emergency department by EMS (final diagnosis after CT scan and X-rays: contusions and abrasions) and an emergency department patient presenting with severe abdominal pain with fever (final diagnosis: ruptured ovarian cyst). Following a denial, patients are left holding a bill for the entirety of their emergency department visit, which they are now responsible for paying on their own.

In response, ACEP has engaged in a multipronged advocacy strategy, employing a range of tactics and building partnerships with key allies along the way. ACEP has worked closely with chapters in the affected states that have been able to very effectively leverage their local ties with policymakers, coalition partners, and the media. State legislation that includes provisions to counter Anthem’s strategy has been introduced in Georgia, Missouri, and Ohio.

In Washington, D.C., ACEP has repeatedly met with key congressional offices for each of the six states to inform them of the policy and provide educational materials to counter Anthem’s claims; chapters are working similarly in the district offices for these members of Congress. As a result, in late December, Sen. Claire McCaskill (D-MO) sent Anthem a letter requesting the insurer provide her office with all internal documents and emails leading to the policy’s implementation. Noting that “patients are not physicians,” the letter reiterated the prudent layperson standard and requested that Anthem explain how the emergency denials policy is not in violation of it. In addition, the senator has asked for communications including discussions about the potential cost savings related to this policy and any associated complaints it may have received.

ACEP also has engaged in substantial public relations efforts along with its chapters, and the resulting media coverage has been very effective in amplifying its advocacy messages and continuing to increase pressure on the insurer. Several stories have received national attention, such as a piece by the Associated Press that was syndicated and carried by more than 100 major outlets across the country, two articles in Modern Healthcare, and most recently a feature on that brought even more attention to the issue and offers of help from additional congressional offices. ACEP’s parody video on the issue also provided an additional opportunity to raise national awareness.

Throughout these efforts, ACEP staff and leadership have met with key Anthem representatives on five separate occasions to voice their concerns and offer constructive alternatives to the policy. Chapters in affected states have met with the insurer, but there has been little headway.

Most recently, ACEP President Paul Kivela, MD, MBA, FACEP, sent an email to contacts at more than 100 emergency department groups asking them to review any Anthem denials they might have in the six affected states and, where possible, provide ACEP with aggregated statistics illustrating them. Having data to cite on the impact and breadth of the Anthem policy is critical to supporting continued advocacy on the issue with state and federal policymakers and making a case for them to take enforcement action. ACEP is also engaged in coalition-building activities with other specialties (eg, the American College of Radiology, the American Academy of Dermatology, and the American College of Surgeons) affected by the damaging Anthem policies in order to maximize resources and bring additional attention to the issue. In addition, ACEP is engaged with consumer groups to ensure the patient voice is heard.

Shortly before press time, Anthem announced it was changing the policy to add additional “always pay” exceptions, including when the emergency department visit was associated with an outpatient or inpatient admission, or when the patient received any kind of surgery, IV medication, or an MRI or CT scan. Anthem also said it will now also request and review medical records before denying claims. While these changes signal the insurer is feeling significant public pressure as a result of a coordinated advocacy effort, ACEP put out a statement noting these changes aren’t nearly enough, and that Anthem must withdraw the policy altogether. Sen. McCaskill put out a similar statement and once again called on the insurer to provide the documents she had previously requested.

Stopping Anthem’s emergency department retroactive denials policy is critical to ensuring it isn’t expanded to the additional eight states in which Anthem has market share and that other payers do not follow with their own dangerous policies.

via ACEP

#anthem #bluecrossblueshield #physicianreimbursement

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