After an extensive evaluation, it turns out that an ED patient with severe abdominal pain does not have appendicitis, only constipation. This is good news medically; financially, it is a different story. The patient may end up fully responsible for the entire cost of the ED visit, deemed “unnecessary” by the insurer. For the revenue cycle, this means lots of complaints, lost revenue, and bad debt.
About 15% of ED visits could be denied if a leading insurer’s policy is implemented nationwide, according to the authors of a recent study.1 Under Anthem Blue Cross/Blue Shield’s “ED review” program, claims can be denied based on the patient’s eventual diagnosis. Several other insurers have since adopted similar policies.
Anthem’s program was put into place to reduce inappropriate use of EDs for nonemergencies, according to spokesperson Joyzelle Davis. “If a consumer receives care for a nonemergency condition at the emergency department when a more appropriate setting is available, Anthem will request more information from the hospital and a statement from the consumer as to why they went to the ED,” says Davis, adding that an Anthem medical director will review the additional information using the prudent layperson standard.
“We know from previous studies that judging the appropriateness of ED visits after the fact is problematic,” says Andrew Chou, MD, MPH, the study’s lead author and an attending physician in the department of emergency medicine at Brigham and Women’s Hospital in Boston. One study revealed that an insurer’s list of nonemergent diagnoses would classify 16% of commercially insured adult ED visits for possible coverage denial.2 However, these visits shared the same presenting symptoms as 88% of ED visits, of which 65% received emergency-level services.
There is ample evidence that retrospective diagnosis-based policies cannot accurately identify unnecessary ED visits. Despite this, some state Medicaid programs collect a $5 or $50 copay for ED visits deemed “inappropriate.” But several of the new policies, including Anthem’s, says Chou, “takes the financial stake to a much higher level by denying any payment for the ED visit.”
Since Anthem is one of the nation’s leading insurers, researchers anticipated that this practice could spread to other companies. That has since proved to be the case, with two other insurers implementing similar policies. Harvard Pilgrim applies a 50% coinsurance for New Hampshire policyholders whose final diagnosis is determined to be nonemergent. Blue Cross and Blue Shield of Texas will not pay anything for an out-of-network ED visit if the insurer later determines the patient should have gone elsewhere for treatment.
To find out how many ED visits could be denied if similar policies continue to be adopted nationally, researchers studied visits of more than 28,000 commercially insured adults. They found that the insurer’s list of nonemergent diagnoses would classify coverage denial for 4.6 million ED visits annually.
“Our findings were consistent with prior studies,” Chou says. People with nonemergent diagnoses can present with diverse symptoms. Some of these, such as chest or abdominal pain, would trigger most outpatient clinicians to refer their patients to the ED for evaluation.
A person with a sudden, severe headache could reasonably fear a ruptured aneurysm, but be diagnosed with a migraine. Since it turned out there was no emergency, the entire cost of the ED visit and diagnostic tests could be denied. Although Anthem has since released a list of exceptions the company says it always will cover (including chest pain, difficulty breathing, seizure, convulsion, fainting, and drug ingestion or overdose), patient safety remains a concern. The well-publicized policies could affect people who avoid going to the ED, fearing a massive bill.
“A patient who needs ED care may not seek it in a timely fashion because they worry they may not be covered,” Chou adds. It is not hard to imagine how patients will react to finding out their insurance is not paying a dime for their ED visit. If patients are unable to pay, it means bad debt for the hospital; exactly how much is unclear. “There’s not a lot of publicly available data to demonstrate how much this impacts hospital revenues,” Chou notes.
Even health insurance companies stand to take a financial hit from their own new ED coverage policies. “The insurer needs to invest a significant amount of resources to review these cases,” Chou says. Interestingly, most appealed cases were ultimately approved and paid, according to a July 2018 report from the office of former Sen. Claire McCaskill, D-MO.
Anthem denied about 12,200 ED claims in Missouri, Kentucky, and Georgia from the last half of 2017, but overturned 62%, 60%, and 70% of the denials that were appealed, according to the McCaskill report.
“There’s really not a clear winner from this policy,” Chou adds. The insurance policies are based on the presumption that it is possible for a person to know whether he or she is experiencing an emergency — in effect, to diagnose themselves. “Many times, that determination is not so clear-cut,” Chou says.
Even triage nurses thought that one-quarter of patients who ended up with a nonemergent diagnosis were either urgent or emergent cases and needed to be seen in a timely fashion, according to the study authors. So what would happen to these patients if they did not seek ED care?
“When we use a policy to try to turn patients away from the ED, sometimes they don’t have another place to go,” Chou says.
Such controversial ED policies are facing some pushback. In July 2018, the American College of Emergency Physicians and the Medical Association of Georgia filed a federal lawsuit asserting that Anthem’s Blue Cross/Blue Shield Healthcare Plan of Georgia is violating the prudent layperson standard (a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms, not their final diagnosis). In a court filing in September 2018, Anthem asked that the lawsuit be dismissed, stating that the goal of the policy is to reduce inappropriate use of EDs. (Editor’s Note: A copy of the entire lawsuit can be found online at: and a copy of Anthem’s motion for dismissal can be found at: .)
As this litigation continues, states are passing legislation that would prevent surprise medical bill. New Jersey’s version (learn more online at: ), which became law in September 2018, meant many changes for patient access. “Working with IT, scheduling, and patient access staff is crucial to having a successful implementation,” says Sandra N. Rivera, RN, BSN, CHAM, patient access director at St. Joseph’s Health in Paterson, NJ. Recently, a meeting was held to review the state’s surprise medical bill law and the new processes that would be needed. Patient financial services, contract management, physician billing, and patient access all were involved.
“Each area assisted in getting the tools the front end would need,” Rivera says. The group gathered information on contracted plans for the facility and physicians. “The challenge for our organization is the decentralized scheduling and check-in at all locations,” Rivera notes.
Ultimately, patient access determined that patients must be notified at scheduling if their insurance plan is in network or out of network, where to find additional information on the website, and that they should call the payer for any questions. Registrars also ask patients to sign an acknowledgement that they received the information.
For patients, these efforts might prevent receiving a surprise medical bill. For patient access, says Rivera, it means lots of “planning, setting up policies, and training staff.”
- Chou S, Gondi S, Baker O, et al. Analysis of a commercial insurance policy to deny coverage for emergency department visits with nonemergent diagnoses. JAMA Netw Open 2018;1:e183731.
- Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. JAMA 2013;309:1145-1153.