Anthem’s ED policy prompted a Missouri law that defines a medical emergency.
The Upshot column in the New York Times on May 19 focused on Anthem’s experiment with denying emergency room visits, arguing that patients should have known that ED care was unnecessary.
One of the anecdotes in the column perfectly illustrates the giant flaw in Anthem’s policy. When “Jason” became short of breath in 2015, he went to the emergency room. He was treated for a panic attack. Two days later, again experiencing shortness of breath and fearing he had heart problems, he returned. His pulse was over 150. How did Anthem handle these two visits?
The first visit was denied because it was coded as a panic attack. The second visit was allowed because it included the diagnosis of breathing trouble. To Anthem’s credit, when Jason appealed the denial, that first visit was paid.
But think about how illogical this situation is. The first time he had symptoms, they denied the care, but they actually allowed the repeat visit. Why? Anthem focused on the final diagnosis code, not the symptoms. It should be obvious to any rational person that the final diagnosis isn’t material for determining whether the patient was acting reasonably in visiting the ED.
Chest pain can be caused by a range of conditions that could include anything from an MI to gas. Obviously, the latter isn’t an emergency. However, a layperson’s ability to determine which of these conditions is actually present is presumably very limited.
In fact, as a layperson, if I attempted to help you determine whether you had an MI or gas, I would be breaking the law: specifically, practicing medicine without a license. Non-physicians are not supposed to make medical judgments. Nevertheless, according to the New York Times and the American College of Emergency Physicians study on which the Times’ story was based, Anthem conducted an experiment in six states – Kentucky, Missouri, Indiana, Ohio, New Hampshire, and Connecticut – performing reviews based solely on the final diagnosis and without the review of medical records.
The good news is that Anthem has reverted to its previous policy. During the experiment, approximately 3 percent of emergency visits in Missouri were being denied. Anthem has now returned to paying well over 99 percent of emergency visits.
As a result of Anthem’s policy, Missouri has passed a new Senate bill: 982. That law defines an emergency medical condition as one that is sudden and would lead a prudent layperson to believe that immediate medical care is required.
The bill does something else very interesting. It requires healthcare professionals and insurance companies to enter into binding arbitration when a health professional provides emergency care to an out-of-network patient and the insurer and healthcare organization are unable to agree on reimbursement. The professional is prohibited from sending a bill to the patient in excess of whatever the arbitration process determines.
There is definite logic to this provision. When a patient has insurance that covers an emergency medical condition, one thing is clear. If they go to the emergency room, either the care provided is reasonable and the insurer should pay, or if the care is unreasonable, the fault lies with the professional or facility. In either case, the patient should not be responsible for the bill.
I recommend that readers adopt this policy. In a fight with an insurer about reimbursement, consider telling the patient that if the insurer won’t pay, they won’t face liability. Note that in many situations, telling a patient that you will accept insurance payment as payment in full can void insurance coverage. A future article will explain why this situation is different.
The bottom line is that when an insured person reasonably thinks they have an emergency medical condition, both the law and common sense say that the patient shouldn’t be responsible for the cost of the medical care.
Program Note:
Listen to David Glaser every Monday on Monitor Mondays, 10-10:30 a.m. ET.
Let me start with a warning. Hardly a day goes by that we don’t hear a story about the wonders of artificial intelligence (AI). And
A Monitor Monday listener recently sent word of what can only be described as a deeply troubling denial of a gender reassignment surgery. The listener
Please log in to your account to comment on this article.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
